Attachment of a migrated MitraClip to the left ventricular apex: A novel case report.

Herein, we report a novel case of emergency surgical mitral valve replacement for severe mitral valve regurgitation (MR) following MitraClip implantation (Abbott Laboratories, Chicago, IL, USA). Recurrent MR was caused because of the migration of the clip due to the destruction of the mitral valve leaflets with Staphylococcus aureus infective endocarditis. Intra-operative transesophageal echocardiography revealed that the clip was stuck to the left ventricular apex. Although the device could not be removed surgically, surgical repair of the valve enabled the patient to recover without any further complications.

Intrathoracic hemorrhage by deep pericardial sutures as detected by transesophageal echocardiography: report of two cases.

BACKGROUND: The use of deep pericardial suture (DPS) is a widely used technique to lift the heart and expose the targeted vessels during off-pump coronary artery bypass grafting (OPCAB). Several reports alert massive bleeding due to DPS, especially for the patients with perioperative administration of tissue plasminogen activator, low molecular weight heparin, and administration of double antiplatelet agents. CASE PRESENTATION: We report two cases of bleeding followed by huge hematoma formation in the left thoracic cavity caused by DPS during OPCAB. In one, bleeding was caused by damage to the left lower pulmonary vein and damage to the diaphragmatic artery in the other. Transesophageal echocardiography (TEE) is a potent tool for detecting complications and identifying the location of bleeding. CONCLUSIONS: TEE is useful for finding hemorrhagic complications and for determining the points of bleeding based on the location of the hematoma.

Anesthetic considerations for cesarean section in a parturient complicated by Scimitar syndrome-like pathophysiology.

BACKGROUND: Pre-existing poor respiratory function is a significant challenge for women to successfully continue pregnancy and accomplish delivery. CASE: Pregnancy and delivery were successfully managed without any maternal or neonatal complications, in a 26-year-old woman with severely impaired respiratory function, due to a unilateral hypoplastic lung, accompanying Scimitar syndrome-like circulation. Hyperventilation, normally observed even at the first trimester, was absent by the end of the second trimester. This would indicate her ventilation must have reached utmost capacity. Premature delivery by the mode of elective cesarean section delivery was, therefore, the most reasonable option. General anesthesia, combined with a continuous epidural infusion of low-concentrate local anesthetics, containing opioid, was sufficient to avoid the need for unexpected mechanical ventilation in intra- and early postoperative periods and to provide excellent post-partum analgesia. CONCLUSION: This combination can be a potent alternative in tailoring anesthesia for cesarean section in women with extremely impaired pulmonary reserve.

[Comparison of Tracheal Intubation Performance between Macintosh Direct Laryngoscope and McGRATH® MAC Video Laryngoscope among Anesthesia Trainees].

BACKGROUND: From April 2013, Macintosh direct laryngoscopes (DL) were replaced by McGRATH® MAC video laryngoscopes (VL), and VL were distributed in all of our operating rooms and used as routine first choice devices. Purpose of this study was to compare the success rate of the first attempt tracheal intubation by the trainees with VL and DL. Incidence of tracheal intubation related injuries were also assessed. MATERIALS AND METHODS: We reviewed anesthesia chart database in which tracheal intubations were provided by anesthesia trainees with experience of less than 3 months. Patient demographics, Mallampati classification and tracheal intubation profiles including type of the tracheal tube and devices were recorded. RESULTS AND DISCUSSION: The first attempt success rate was 78.6% with DL and 92.8% with VL (P < 0.001). More than 2 repeated trial incidence was 5.2% with DL and 1.3% with VL (P < 0.001). Incidence of mucosal injury was lower with DL than VL. CONCLUSIONS: VL notably improved the first success rate of tracheal intubation compared with DL among trainees.

Simultaneous comparison of thrombogenic reactions to different combinations of anticoagulants, activated clotting times, and materials.

Thrombogenic reactions under multiple interactions of pharmacological agents, doses, and materials have not been well understood yet. The aim of this study was to investigate the ability to simultaneously compare thrombogenic reactions to different combinations of anticoagulants, doses, and blood-contacting materials, in a single human blood using an in vitro test method. Four venous blood samples were drawn from each of six healthy volunteers into syringes that contained two different amounts of heparin and argatroban to set the activated clotting time (ACT) to approximately 200 or 500 s, respectively. The four blood samples from each volunteer were immediately poured into two clinical-grade extracorporeal circulation tubes: a polyvinyl chloride (PVC) tube and a poly(2-methoxyethyl acrylate)-coated (PMEA) PVC tube. These tubes with an inner diameter of 12.7 mm were rotated at 183 rpm in a 37°C chamber for 10 min. The results indicated that the in vitro thrombogenicity test method was capable of assessing differences in platelet factor 4 and ß-thromboglobulin increases among different combinations of the two materials, two anticoagulants, and two ACTs. Higher amounts of total plasma proteins were absorbed on PVC tubes than on PMEA-coated tubes when using the same anticoagulant and dose. These data elucidate that the in vitro thrombogenicity test method is useful for the simultaneous quantitative evaluation of the influences of various combinations of materials, pharmacological agents, and doses on thrombogenicity in a single human blood.

[Usefulness of the new version 3.02 of Vigileo monitor for anesthetic management in anaphylactic shock: a case report].

We studied the utility of Vigileo monitor for grasping hemodynamics with a patient in a state of anaphylactic shock. The stroke volume variation (SVV) predicts fluid responsiveness of normal cases. In the anaphylactic shock resulting from biased blood distribution, not only blood pressure but also pulse pressure markedly decreased within a couple of minutes. SVV is calculated from the standard deviation of pulse pressure. Therefore the SVV could be overestimated during anaphylactic shock. A former version of Vigileo monitor underestimated the arterial pressure-based cardiac output (APCO) due to the underrating of a single stroke volume (SV) in a range of systemic vascular resistance (SVR) below 800 dyne x sec(-1) x cm(-5). The version 3.02 Vigileo monitor allowed for more accurate estimation of SV because its new algorithm was able to revise the apparently low SVR derived from the arterial waveform characteristics and hence provided more realistic SV and APCO values. It was thus concluded that this ver. 3.02 is useful for anesthetic management of the anaphylactic case.

Cross-talk between beta(1)-adrenoceptors and ET(A) receptors in modulation of the slow component of delayed rectifier K(+) currents.

Delayed rectifier K(+) currents (I(K)) play a critical role in determining cardiac action potential duration (APD). Modulation of I(K) affects cardiac excitability critically. There are three components of cardiac delayed rectifier, and the slowly activating component (I(Ks)) is influenced strongly by a variety of stimuli. Plasma levels of noradrenaline and endothelin are elevated in heart failure, and arrhythmias are promoted by such humoral abnormalities through modulation of ion channels. It has been reported that protein kinase A (PKA) and protein kinase C (PKC) modulate I(Ks) from human minK in a complex manner. In the present study, we coexpressed human minK with the human beta(1)-adrenoceptor (hbeta(1)AR) and the endothelin receptor subtype A (hET(A)R) in Xenopus oocytes and investigated the effects of receptor activation on the currents (I(Ks)) flowing through the oocytes. ET-1 modulated I(Ks) biphasically: a transient increase followed by a decrease. The PKC inhibitor chelerythrine completely inhibited the effects of ET-1. Intracellular EGTA abolished the transient increase by ET-1 and partially inhibited the subsequent decrease in the currents. When I(Ks) was increased by 10(-6) M isoproterenol (ISO), ET-1 did not increase but rather decreased the current to an even greater extent than under control conditions. In addition, the effects of ISO on I(Ks) were suppressed by ET(A)R stimulation. These data indicate that I(Ks) can be regulated by cross-talk between the ET(A)R and beta(1)AR systems in addition to direct regulation by each receptor system.

Dissociation of E-4031 from the HERG channel caused by mutations of an amino acid results in greater block at high stimulation frequency.

OBJECTIVE: We have reported identification of the amino acid whose mutation reduces effects of quinidine on the HERG channel. Although the residue (isoleucine at 647) is not in the recently reported methanesulfonanilide binding site, a single concentration of E-4031 (10 microM) was less effective to I647 mutant channels than wild type HERG channel. We designed the present experiment to further investigate influence of mutations at 647 on the effects of methanesulfonanilides. METHODS AND RESULTS: HERG channels were expressed in Xenopus oocytes and their currents were measured by a two-microelectrode voltage clamp method. Of the two mutations initially studied (I647A and I647F), the I647F had a greater influence and differentially affected the effects of dofetilide and E-4031. The IC(50) for dofetilide of the two mutant channels (I647A and I647F) was increased only 2-fold, but the IC(50) for E-4031 was increased 6-fold (I647A) and 14-fold (I647F). Aromatic residues other than phenylalanine were then substituted for I647, and found to reduce the effects of E-4031. Whereas E-4031 dissociated from the mutant channels during rested state, dofetilide little dissociated. The mutant channels that showed recovery from E-4031 block were inhibited greater at 1 Hz than at 0.1 Hz. CONCLUSIONS: The present results indicate that dissociation of a drug from the HERG channel results in greater block at high frequency. Although the mechanism by which the mutations cause the dissociation of E-4031 is uncertain, it is noteworthy that one methanesulfonanilide dissociates from the channel more easily than another.