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A 97-year-old woman with severe back pain was transferred to our hospital. She was able to perform activities of daily living independently and had no neu- rological deficit or dementia before her admission. Con- trast-enhanced computed tomography revealed a rup- ture in the descending aorta and thrombosed type A aortic dissection. We carefully explained the need for and the risks associated with surgery to the patient and her family. After an informed consent had been obtained, she was taken to the operating room for an emergency surgery. Anesthetic management was uneventful. Trans- esophageal echocardiography was useful to evaluate her cardiac function and aortic dissection. We per- formed replacement of the total aortic arch and descending aorta successfully. On the 55th postopera- tive day, she was transferred to another hospital to undergo further physical therapy. The total hospital- ization cost was nearly 9.8 million yen. The medical cost was high in our case. In cases of nonagenarians who require an emergency cardiac surgery, we should consider the patients' age, preoperative activities of daily living, and postoperative quality of life when making decisions on surgery. The patient in our case needed to be carefully treated for airway and swallow- ing management in the early perioperative period.

Madelung's disease is a rare disorder characterized by multiple, symmetric fatty tissues. The patient, 72-year-old man was admitted to our hospital for abdominal surgery for liver cancer. He had extreme fatty accumulations involving head and neck. We expected difficult airway because of his fatty tissues, and we perfomed awake intubation by Airway Scope. We confirmed the airway by using tube exchanger at extubation. We should choose a proper airway management technique to reduce the incidences of airway complications.

The perioperative management of pheochromocytoma is challenging for anesthesiologists and persistent hypotension secondary to cathecholamine depletion after tumor resection can be refractory to treatment. A 64-year-old man underwent right adrenalectomy for treatment of massive pheochromocytoma. Doxazosin administration was started and increased gradually to 12 mg daily. He was premedicated with doxazosin on the day of the surgery. Induction was uneventful but there was a sudden increase of blood pressure with tachycardia on handling of tumor which was controlled by intravenous remifentanil, landiolol, diltiazem, and magnesium sulfate. With dissection of the tumor, the blood pressure dropped to 65/40 mmHg, which was resistant to fluid and cathecholamine treatment. After commencement of low dose vasopressin administration (two boluses of 0.08 U followed by 1.6 U x hr(-1)), blood pressure gradually recovered to normal ranges. Low dose vasopressin can be safely used to treat postadrenalectomy hypotension and also can reduce the cathecholamine dose.

Background: Right thoracotomy is an alternative surgical technique for mitral valve reoperation. The purpose of this study is to determine whether right thoracotomy for mitral valve reoperation affects its perioperative outcomes and complications., Methods: We investigated the perioperative events in consecutive mitral valve reoperations between January 2006 and November 2009. Demographic, intraoperative and postoperative data were collected and analyzed retrospectively., Results: Five right thoracotomy cases and 22 repeated sternotomy cases were included. Thoracotomy group needed more platelet transfusion (median, 20 units in thoracotomy; 10 units in sternotomy; P=0.047). We had a higher frequency of adrenaline administration (60% in thoracotomy; 4.6% in sternotomy; P=0.005) and needed more doses of dobutamine in thoracotomy group (median, 16.0 microg x kg(-1) x min(-1) in thoracotomy ; 7.5 microg x kg(-1) x min(-1) in sternotomy; P=0.037) to wean them from cardiopulmonary bypass. Right thoracotomy did not reduce cardiopulmonary bypass time (median, 265 min in thoracotomy ; 199 min in sternotomy; P=0.126). We experienced two serious complications requiring reoperation in thoracotomy group, but diagnosed them with intraoperative transesophageal echocardiography., Conclusions: When we choose right thoracotomy for mitral valve reoperation, we should prepare more blood products and inotropic agents and should evaluate cardiac function by using intraoperative transesophageal echocardiography.

Background: Remifentanil may be beneficial in patients undergoing cardiac surgery, by attenuating the neurohumoral stress response to surgical stimulation and inflammation evoked by cardiopulmonary bypass (CPB)., Methods: We retrospectively examined blood glucose monitored every 30 minutes during CPB and insulin dose in patients during CPB under remifentanil anesthesia (remifentanil group) and those under low dose fentanyl anesthesia (fentanyl group) in adult cardiac surgery. Furthermore we also investigated incidence of atrial fibrillation within 72 hours after surgery in both groups., Results: There were 35 patients in remifentanil group and 22 patients in fentanyl group. Although blood glucose at the beginning and the end of CPB in both groups were not different, remifentanil group showed lower maximum blood glucose (median 172 mg x dl(-1), interquatile range 156-205 mg x dl(-1)) during CPB than in fentanyl group (197 mg x dl(-1), 176-219 mg x dl(-1); P = 0.009). Significantly less insulin was administered during CPB in remifentanil group than in fentanyl group. Incidence of postoperative atrial fibrillation was similar between the groups., Conclusions: Maximum blood glucose was lower and less insulin was administered during CPB in remifentanil group. These data may suggest that remifentanil reduce stress response to surgical stimulation in cardiac surgery.

A 65-year-old man received general anesthesia for extended esophagectomy with 3-field lymph node dissection. Although he was without many risk factors for stroke except smoking, chest computed tomography performed preoperatively showed a small calcification at the origin of the left subclavian artery on the aortic arch. The anesthetic course was uneventful. On the first postoperative day, when the patient awoke from sedation, he presented with left conjugate deviation of the eyes and right hemiparesis. Immediate computed tomography scanning revealed cerebral infarction in the area of the left middle cerebral artery associated with hyper density indicating a thrombus. Both transthoracic echocardiography and carotid ultrasonography were performed to determine the cause of stroke. As a result, severe atheromatous stenosis of the left internal carotid artery was noticed, while there was neither thrombus nor shunt in the heart. Intraoperative cerebral emboli during surgical manipulation of the carotid artery were strongly suspected as a possible cause of the stroke. Preoperative carotid screening by ultrasonography may be advocated to identify such a patient as the present case with occult carotid atherosclerosis at risk for a subsequent stroke.

A retrospective study was performed to determine the incidence of perioperative stroke in patients with previous history of cerebrovascular disease (CVD). One hundred and seventy eight out of 20048 patients who underwent anesthesia and surgery during the period of 1985 to 1989 had history of prior CVD. Of them, 137 patients were managed with general anesthesia and 41 with regional anesthesia. Factors analyzed were interval between the prior CVD and the operation, intraoperative hemodynamic changes, perioperative changes in the hematocrit and urinary output, and postoperative neurological complications. Postoperative neurological complications occurred in 31 of the patients given general anesthesia (delayed awakening in 26, dementia syndrome in 6 and deterioration of paralysis in 1), whereas only one patient developed dementia syndrome postoperatively in those given regional anesthesia. None of the patients developed a postoperative stroke. There was no direct relationship between the factors analyzed and the incidence of postoperative neurological complications. Further studies are needed to identify more precisely factors contributing to the occurrence of cerebrovascular complication in a high risk patients.