T . Takeichi et al .: J Extra Corpor Technol 2024 , 56 , 120 – 124 121
Figure
1 . The figure of after weaning CPB course . Sys ABP .: Systolic arterial blood pressure ; Sys PAP .: Systolic pulmonary artery pressure ; mean CVP .: Mean central venous pressure ; SvO 2 .: Heart rate ; HR .: Mixed venous oxygen saturation ; CI .: Cardiac index ; iNO .: Inhaled nitric oxide .
resistance ( PVR ), 552 dyne / s / cm 5 . We planned to redo MVP under totally endoscopic . EuroSCORE II was 11.9 .
Following induction of general anesthesia , a pulmonary artery ( PA ) catheter ( Swan-Ganz CCOmbo model : 744HF75 , Edwards ( r ), USA ) was inserted via an introducer ( 8.5 Fr ) placed in the right internal jugular vein . The patient underwent MICS redo MVP . CPB was established with a venous cannula 23 / 25Fr ( MICS Cannulae ; LivaNova , Tokyo , Japan ) placed in the right femoral vein and an arterial cannula 18Fr ( PCKC-A , MERA , Tokyo , Japan ) placed in the right femoral artery . Centrifugal pump ( MERA Centrifugal Pump HCF-MP23 , SENKO MEDICAL INSTRUMENT , Inc ., Tokyo , Japan ) was used for CPB , with a target pump flow was 2.4 L / min per m 2 . Phenylephrine and noradrenaline were administered to maintain a mean arterial pressure above 60 mmHg . Anticoagulation was given at an initial dose of 250 IU / kg ( 15000 IU ) to achieve a target activated clotting time of at least 480 s and if the activated clotting time was less than 480 s , an additional dose of 4000 IU was given . A CDI Blood Parameter Monitoring System 500 ( Terumo , Tokyo , Japan ) was recalibrated every 30 min , and an arterial blood gas sample was also checked every 30 min . The patient was cooled to 31 ° C . Cardiac arrest was achieved using antegrade cardioplegia , and the mitral valve approach exposure was performed through the left atrium . Redo MVP was carried out as planned . Weaning from CPB was performed using dobutamine 0.03 ug / kg / min and noradrenaline 4.9 ug / kg / min ( Fig . 1 ). CPB time and aortic cross-clamp time were 235 min , and 116 min , respectively . Immediately after weaning CPB , protamine was administrated dose of 13 mg . Protamine was administrated over 10 min from the peripheral venous route by dripping . At the same time , the dose of dobutamine and noradrenaline was decreased to 0.02 ug / kg / min and 3.9 ug / kg / min , respectively . Ten minutes after CPB weaning , sys PAP increased from 33 mmHg to 62 mmHg . However , systolic arterial blood pressure ( sys ABP ), mixed venous oxygen saturation ( SvO 2 ), heart rate ( HR ), CI , and CVP were 109 mmHg , 72 %, 50 bpm , 2.9 L / min / m 2 , and 13 mmHg , and no major changes were observed . Moreover , 30 min later , the sys PAP was 80 mmHg . Sys ABP decreased slightly , but , SvO 2 , HR , CI , and CVP were stable . Considering the adverse impact of protamine , iNO therapy was started with a concentration of 20 ppm . Also , the administration of milrinone was started at 0.22 ug / kg / min . Ten minutes after iNO therapy was started , sys PAP decreased to 63 mmHg , while , sys ABP increased to 99 mmHg . SvO 2 , HR , CI , and CVP did not change significantly , respectively . The operation time was 303 min , and the total fluid balance was 9096 mL .
After entering the ICU , sys PAP decreased to 35 mmHg , and sys ABP was 100 mmHg . The parameters such as SvO 2 , HR , CI , and CVP were also stable ( Fig . 2 ). P / F ( PaO 2 : 109 mmHg , FiO 2 : 0.5 ) ratio was 218 . The administration of dobutamine was 2.6 ug / kg / min , noradrenaline was 0.05 ug / kg / min , and milrinone was 0.22 ug / kg / min . After 3 h of entering the ICU , iNO concentration was gradually reduced , and after 18 h , iNO therapy was stopped , and extubation could be performed . A postoperative chest x-ray ( CXR ) was revealed ( Fig . 3a – c ). Overall pulmonary edema appeared immediately postoperative and the day after surgery ( Fig . 3a , b ). 5 days after surgery , CXR was gradually improved ( Fig . 3c ). Length of stay in the ICU was 2 days .