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A 30-year-old Thai woman (gravida 1, para 0) at 33 weeks gestation was referred to our hospital due to acute right ventricular failure. Pulmonary vasodilators were gradually administered before delivery. On the verge of sudden postpartum cardiac circulation collapse, she was resuscitated with veno-arterial extracorporeal membrane oxygenation (VA-ECMO). Abdominal compartment syndrome was developed in the early period of the mechanical support. Knowledge of pathophysiology about pulmonary arterial hypertension during pregnancy was applied. Atrial septostomy was the effective procedure for discontinuing mechanical support (VA-ECMO) corresponding to the suitable timing for maximal effect of pulmonary vasodilators. The patient and her child were safe and discharged in 2 months after the admission.

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Objective: To examine the incidence and risk factors of early neurological complications after cardiac or aortic surgery using cardiopulmonary bypass technique in King Chulalongkorn Memorial Hospital, Thailand. Materials and Methods: The present study was a retrospective cohort study. Clinical data of adult patients that underwent cardiac or aortic surgery using cardiopulmonary bypass technique in 2018 were reviewed from the electronic medical record in the authors’ center. Results: Early postoperative neurological complications occurred in 33 (8.3%) of the 400 patients. Twenty of them (60.6%) had non-specific encephalopathy, three (9.1%) had hypoxic-ischemic encephalopathy, five (15.2%) had provoked seizure, four (12.1%) had cerebral infarction, and one (3.0%) had intracranial hemorrhage. Associated clinical factors included history of essential hypertension [adjusted odds ratio 3.448 (95% CI 1.266 to 9.391)], combined coronary artery bypass grafting and valve surgery [adjusted odds ratio 4.759 (95% CI 1.182 to 19.170)], multi-valve surgery [adjusted odds ratio 5.201 (95% CI 1.227 to 22.049)], aortic surgery [adjusted odds ratio 17.260 (95% CI 4.168 to 71.468)], higher midazolam dosage [adjusted odds ratio 1.009 (95% CI 1.002 to 1.015)], higher serum lactate prior to discontinuing cardiopulmonary bypass [adjusted odds ratio 1.263 (95% CI 1.093 to 1.460)], and presence of intraoperative intra-aortic balloon pump use [adjusted odds ratio 6.160 (95% CI 1.883 to 20.150)]. Conclusion: Early postoperative neurological complications rate of cardiac or aortic surgery using cardiopulmonary bypass technique in the present study settings was 8.3%. Preoperative and intraoperative clinical factors associated with such complications were the history of essential hypertension, the type of surgery such as combined coronary artery bypass grafting and valve surgery, multi-valve surgery, and aortic surgery, the higher midazolam dosage, the higher serum lactate prior to discontinuing cardiopulmonary bypass, and the presence of intraoperative intra-aortic balloon pump use. Keywords: Cardiac surgery; Aortic surgery; Cardiopulmonary bypass; Postoperative neurological complications; Encephalopath

Background. Infective endocarditis caused by the dimorphic fungus Histoplasma capsulatum is extremely rare, occurring predominantly in individuals with prosthetic heart valves and HIV infection. To our knowledge, no case of H. capsulatum native valve endocarditis has been reported in Asia. Methodology. A descriptive study was carried out at King Chulalongkorn Memorial Hospital, Bangkok, Thailand, in 2020. Results. A previously healthy 34-year-old man developed fever, umbilicated skin lesions, oral ulcers, hoarseness of voice, severe weight loss, and progressive dyspnea over the course of one week. Facial umbilicated papules, nodular ulcers in his tongue and palate, a diastolic rumbling murmur at the mitral valve, diffuse fine crackles in both lungs, and engorged neck veins were detected during the examination. Skin scraping of the facial lesion revealed both extracellular and intracellular yeasts with buddings, 2–4 μm in size on Wright’s stain. Transthoracic echocardiography demonstrated a left ventricular ejection fraction of 54 percent, severe rheumatic mitral stenosis, and multiple oscillating masses in the anterior mitral valve leaflet ranging in dimension from 1.5 to 2.4 cm. The HIV antibody test was negative. H. capsulatum endocarditis was diagnosed, and liposomal amphotericin B was administered. Due to cardiogenic shock, emergency open-heart surgery was conducted one day after admission. However, he died of multiorgan failure four days after the operation. The skin and vegetation cultures finally grew H. capsulatum after 1 week of incubation. Conclusions. To date, there has been handful of cases of H. capsulatum native valve endocarditis in non-HIV-infected patients. We report herein the first case in Thailand. Umbilicated skin lesions, especially combined with oral mucosal lesions, are a clinical clue that leads to the correct diagnosis of the causative organism.