T . Takeichi et al .: J Extra Corpor Technol 2025 , 57 , 32 – 37 33
Figure
1 . ( a ) Preoperative contrast-enhanced CT of the atherosclerotic and artheromic aorta . ( b , c ) The aortic arch and descending aorta indicate intimal 6.48 mm and 7.89 mm of intimal thickening of the aortic arch and descending aorta combined with calcification . CT : Computed Tomography .
Case report
The patient ( height 164 cm ; weight 54 kg ) had a history of coronary artery bypass grafting ( CABG ) left internal thoracic artery to left anterior descending artery ( LITA-LAD ), aorta to radial to posterior descending artery ( Ao-RA- # 14 ), and gastroepiploic artery to posterior descending branch to atrioventricular branch ( GEA- # 4PD- # 4AV ) 4 years ago . At this time , the patient was diagnosed with severe mitral regurgitation and patent foramen ovale ( PFO ) by transesophageal echocardiography ( TEE ). The contrast-enhanced CT scan revealed calcification observed from the Asc Ao extending the abdominal aorta . Also , the aortic arch and descending aorta were observed intimal thickening > 4.0 mm ( 6.48 mm and 7.89 mm of intimal thickening in the aortic arch and descending aorta ) combined with calcification ( Figures 1a – 1c ). The patient had a low left ventricular ejection fraction ( 44 %) and EuroSCORE ( European System for Cardiac Operative Risk Evaluation ) was 13 %. The totally endoscopic procedure was planned for redo-MVP under systemic hyperkalemia without cross-clamping due to being difficult aortic cross-clamping . Moreover , to prevent postoperative cerebral infarction , the Asc Ao and FA were planned to establish CPB . Table 1 indicates CPB management and postoperative outcomes including preoperative CPB plan .
Following induction of general anesthesia , the patient underwent redo-MVP via right thoracotomy procedure . CPB was established with a venous cannula 23 / 25Fr ( MICS Cannulae ; LivaNova , Tokyo , Japan ) placed via the right femoral vein ( FV ) and an arterial cannula 18Fr ( PCKC-A , MERA , Tokyo ,
Japan ) placed in the right FA . Because it is possible to ensure total flow , we chose 18Fr in FA in response to what may arise when Asc cannulation causes any troubles . Until Asc Ao cannulation , CI ( cardiac index ) was kept at less than 1.0 L / min / m 2 to prevent cerebral plaque embolism . After an arterial cannula 14Fr ( PCKC-A , MERA , Tokyo , Japan ) was placed in the Asc Ao , CPB was managed from 2.0 to 2.6 L / min per m 2 of the target CI . Asc Ao cannulation was performed two-window technique . Phenylephrine and noradrenaline were administered to maintain mean arterial blood pressure ( mABP ) above 60 mmHg . 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 26 ° C . To obtain cardiac arrest , 800 mL of the hyperkalemia solution ( 500 mL of bicarbonate ringer solution with 50 mL of KCL 10 mEq / L , 20 mL of MgSO 4 , and 100 mg of 2 % lidocaine ) administered bolus infusion from CPB circuit . To maintain cardiac arrest , we continuously infused hyperkalemia solution , and the target of a blood potassium level was managed at 9 mEq / L . Due to the influence of aortic regurgitation , it was difficult to get a good vision . Therefore , we performed MVP combined with circulation arrest . When a left ventricular vent through the MV was useful in preventing aortic valve release , we started rewarming the temperature and lowering potassium levels in the blood by using dilutional ultrafiltration ( DUF ) and administering continuous furosemide ( 45 mL of 20 % mannitol + 50 mg of furosemide ) at 10 mL / h . Weaning from CPB was performed using inotropes ( 5.5c of dobutamine and 0.03c of noradrenaline ).