Cardiac surgery for a right atrial myxoma with traumatic intracranial hemorrhage: a case report.

BACKGROUND: The timing of cardiac surgery with cardiopulmonary bypass (CPB) for intracranial hemorrhage is controversial. CASE PRESENTATION: We report the case of an 82-year-old woman who was transferred to our hospital because of a head injury. Brain computed tomography (CT) revealed traumatic intracranial hemorrhage, and transthoracic echocardiography revealed a giant right atrial myxoma. After confirming the disappearance of intracranial hemorrhage on brain CT, cardiac surgery with CPB was performed, which was uneventful. CONCLUSIONS: For an uneventful surgery, the optimal timing of cardiac surgery with CPB in patients with giant right atrial myxoma and intracranial hemorrhage should be based on brain CT.

Case Report: Spontaneous Postpartum Quadruple Cervicocephalic Arterial Dissection With a Heterozygous COL5A1 Variant of Unknown Significance.

Pregnancy-associated cervicocephalic arterial dissection is rare, and its pathophysiology remains poorly understood. Despite the hypothesized contribution to pathogenesis, connective tissue diseases and genetic factors are rarely identified in clinical cases. We describe a case of postpartum arterial dissection involving all four cervicocephalic arteries resulting in acute cerebral infarction. The patient underwent successful endovascular thrombectomy and angioplasty and recovered fully without sequelae. Genetic screening for connective tissue diseases identified a heterozygous missense COL5A1 variant with unknown clinical significance. Two genetically related family members later developed arterial abnormalities, and one of them tested positive for the same COL5A1 gene variant as our patient, while the other was scheduled for genetic testing. The extensive clinical presentation of our patient and the prevalence of arterial abnormalities in her family warrant further assessment of the association between the identified COL5A1 gene variant and the pathogenesis of arterial dissections.

A case of plastic bronchitis after mitral valve surgery in an adult.

Plastic bronchitis is a rare and fatal disease that is characterized by the presence of long dendritic bronchial casts in the airway. It is encountered most frequently in children with congenital heart disease after correction surgery. We reported a case of plastic bronchitis after mitral valve surgery in a 70-year-old woman.

Independent lung ventilation combined with HFOV for a patient suffering from tracheo-gastric roll fistula.

This case report describes the difficult respiratory management of an esophageal cancer patient with acute respiratory distress syndrome (ARDS) and systemic inflammatory response syndrome (SIRS) caused by a postoperative tracheogastric roll fistula. A single-lumen tracheal tube could not seal the fistula, and therefore a double-lumen tracheal tube (DLT) for the left side was used. Although the proximal cuff of the DLT failed to seal the fistula, independent lung ventilation (ILV) improved blood gas levels. During right thoracotomy, the left lung was ventilated conventionally with 5 cmH2O positive end-expiratory pressure (PEEP), and in addition, high-frequency oscillation ventilation (HFOV) to the right lung was employed. This combination allowed the maintenance of adequate oxygenation, and the HFOV to the right lung decreased the PaCO2 level during surgery without interruption of the surgical field. These techniques provided the opportunity to successfully remove a necrotic gastric roll and achieve closure of the fistula using an intercostal muscle flap. This report documents and discusses the difficulty of performing appropriate anesthetic management of a patient with these complex complications after esophageal surgery.

[A case of anaphylactic shock in an elderly man following protamine sulfate administration during emergent off-pump coronary artery bypass grafting].

An 80-year-old diabetic man undergoing emergent off-pump coronary artery bypass grafting for acute myocardial infarction developed anaphylactic shock immediately following administering a small dose of protamine sulfate. Preoperative examination revealed atrial fibrillation, severe three-vessel coronary artery disease and impaired left ventricular function with ejection fraction of 40% and severe septal as well as apical hypokinesis and akinesis. After successful completion of coronary bypass grafting, a total of 40 mg of protamine sulfate was given through the central venous line. Three minutes after protamine administration, profound hypotension occurred. Pulmonary artery pressure was low and the left ventricle was almost empty by transesophageal echocardiography. Hypotension was refractory to rapid administration of 2 l of crystalloid and albumin, and repeated administrations of phenylephrine. Blood pressure finally returned towards baseline after infusion of norepinephrine 0.2 microg x kg(-1) x min(-1) and epinephrine 0.1 microg x kg(-1) x min(-1). Hemoconcentration and impaired oxygenation were also noted. The situation suggested anaphylactic shock due to protamine. He had diabetes mellitus for 20 years and been treated by protamine containing insulin. Postoperative interview revealed that the patient had experienced urticaria over the abdominal area with neutral protamine hagedorn (NPH) insulin administration. This history suggested that the patient had been sensitized by protamine before surgery. Although it is rare to experience anaphylactic shock due to protamine, it is important to elicit the detailed allergic history to insulin in diabetic patients. Because anaphylactic shock still carries high mortality even in a patient without cardiac disease, we were lucky to save this elderly patient with acute myocardial infarction and compromised left ventricular function.