In Japan, an ever-present problem in the preoperative evaluation of patients with ischemic heart disease is that although such evaluations are based on Western data, these data serve as the basis for determining perioperative risk in Japanese patients. To remedy this problem, the Cardiac Ischemia and Anesthesia Research Committee was formed in 1997 and has conducted studies of perioperative complications in noncardiac surgery in Japan. In two retrospective studies in 1997, the proportions of patients with ischemic heart disease were 3.9% and 3.1%, approximately one tenth the rates reported in Europe and the United States. The incidences of perioperative cardiac complications in patients with ischemic heart disease were 16.4% and 13.2%, not widely divergent from rates reported in Europe and the United States. To investigate the baseline characteristics involved in perioperative complications, we conducted a prospective study of 237 patients classified as having intermediate risk for perioperative cardiac complications according to the American College of Cardiology/American Heart Association Guidelines for Perioperative Cardiovascular Evaluation for Noncardiac Surgery. We found that the prominent factor in intraoperative cardiac complications was the presence of hypertension (odds ratio = 2.911). Factors contributing to postoperative cardiac complications included those reflecting coronary lesion severity and cardiac dysfunction (history of heart failure; odds ratio = 6.884, coronary risk index grade; odds ratio = 2.884, and a history of intervention; odds ratio = 4.774).

BackgroundEsophageal submucosal hematoma is a rare complication after endovascular surgery. We report a case of an esophageal submucosal hematoma which may have been caused by rigorous cough during extubation.Case presentationA 75-year-old woman underwent endovascular treatment for unruptured cerebral aneurysm under general anesthesia. The patient received aspirin and clopidogrel before surgery and heparin during surgery. Activated clotting time was 316 s at the end of surgery. Protamine was not administered and continuous infusion of argatroban was started after surgery. She had a rigorous cough during removal of the tracheal tube and reported retrosternal discomfort postoperatively. She developed hemorrhagic shock after massive hematemesis. A diagnosis of esophageal submucosal hematoma was made by endoscopic examination and computed tomography. Hemostasis was achieved by compression with a Sengstaken-Blakemore tube and endoscopic cauterization. Blood pressure was recovered by blood transfusion. Endoscopic examination performed 7 days after surgery showed that esophageal submucosal hematoma had almost disappeared and slough had adhered to the mucosal laceration. The patient showed good recovery and was discharged 21 days after surgery.ConclusionsCareful extubation and postoperative observation are required in patients receiving antiplatelet and anticoagulant therapy.

Whereas clotting factor activation sthenia is common in Europe and North America, thrombocyte function sthenia occurs in Japanese patients. This difference may account for the differing incidences of phlebothrombosis in Japanese and white populations.

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