A 66-year-old man with thrombocytosis was brought to our hospital to undergo removal of a left ventricular thrombus. He had developed cerebral infarction 6 days before presenting to the hospital and suffered from right incomplete hemiparalysis. Blood tests on admission revealed his platelet count to be 124.3 × 104/μl. The urgent removal operation was performed under general anesthesia. For carrying out extracorporeal circulation (ECC), approximately three times as much heparin as expected was needed, as well as antithrombin III (AT III) administration. This met the definition of heparin resistance. The thrombus was removed and surgical left ventricular reconstruction was performed. Aspirin and warfarin were initiated on postoperative day 5. A bone marrow biopsy was performed on postoperative day 8, which revealed hypercellular marrow with megakaryocyte proliferation, and the patient was diagnosed as having essential thrombocythemia (ET). Although hydroxycarbamide administration started on postoperative day 10, his platelet count increased to 290.7 × 104/μl on postoperative day 13. The counts descended gradually, and on postoperative day 34, his platelet count reached the normal range and he was discharged from the hospital. In the perioperative period, his new neurologic abnormality did not appear. Addition of heparin, administration of AT III, and coating the cardiopulmonary bypass circuit with heparin or macromolecular polymer prevented clot formation and enabled safe ECC in a patient with ET and a high platelet count.

Background: Peripartum cardiomyopathy is an uncommon form of heart failure that occurs in otherwise healthy women during pregnancy or until 5 months postpartum. Here, we report a rare case where a female patient underwent cesarean section after the occurrence of preeclampsia and intrauterine fetal death, and developed peripartum cardiomyopathy following postsurgical respiratory distress. The prompt initiation of inotropic drug and bromocriptine therapy quickly restored cardiac function. Case presentation: The patient was a 36-year-old woman who underwent emergency cesarean section for a previous preeclampsia and an intrauterine fetal death that occurred after 24 weeks of pregnancy. In addition, the patient had an extremely low platelet count of 5000/μL on admission. She had been diagnosed as idiopathic thrombocytopenic purpura at the age of 29 years old and treated with prednisolone at 15 mg/day. Therefore, the cesarean section was performed under general anesthesia. The patient did not exhibit respiratory or hemodynamic dysfunction during surgery. However, she developed respiratory distress with sinus tachycardia after extubation and was transferred to the intensive care unit. A chest radiograph showed butterfly shadows, and transthoracic echocardiogram confirmed the reduction of left ventricle contractility (ejection fraction 20%). She was diagnosed with peripartum cardiomyopathy and treated immediately with intravenous milrinone, oral bromocriptine, and angiotensin-converting enzyme inhibitor. Respiratory and hemodynamic function improved rapidly, and the patient was moved to the general ward 2 days after surgery. Fourteen days after surgery, the patient had an ejection fraction of 57%. The patient recovered without any further complications and was discharged 24 days after surgery. Conclusion: A sudden case of peripartum cardiomyopathy was successfully managed by a prompt diagnosis and treatment with inotropic agents and bromocriptine.

Different ventilatory strategies may affect survival in septic patients requiring mechanical ventilation. In this retrospective before-and-after study, we examined the effects of permissive hypoxia and hyperoxia avoidance on mortality in mechanically ventilated adult (≥18 years) septic patients at a Japanese university hospital. In April 2017, our hospital’s mechanical ventilation policy changed from a conventional oxygenation target (SpO2: ≥96%.) to more conservative targets with permissive hypoxia (SpO2: 88-92% or PaO2: 60 mmHg) and hyperoxia avoidance (reduced oxygenation for PaO2 >110 mmHg). Patients were divided into a pre-change group (April 2015 to March 2017; n=83) or post-change group (April 2017 to March 2019; n=130). Using a multiple logistic regression model, we examined the association of the post-change group with intensive care unit (ICU) mortality. The post-change group did not have a significantly lower adjusted ICU mortality (odds ratio: 0.67, 95% confidence interval: 0.33-1.43; P=0.31) than the pre-change group. However, there were significant differences in mechanical ventilation duration (pre-change: 11.0 days, post-change: 7.0 days; P=0.01) and ICU stay (pre-change: 11.0 days, post-change: 9.0 days; P=0.02). Although the new ventilation policy did not affect ICU mortality, the reductions in mechanical ventilation duration and ICU stay may improve patient turnover and ventilator access.

Background. Septic patients often require mechanical ventilation due to respiratory dysfunction, and effective ventilatory strategies can improve survival. The effects of the combination of permissive hypoxia and hyperoxia avoidance for managing mechanically ventilated patients are unknown. This study examines these effects on outcomes in mechanically ventilated septic patients. Methods. In a retrospective before-and-after study, we examined adult septic patients (aged ≥18 years) requiring mechanical ventilation at a university hospital. On April 1, 2017, our mechanical ventilation policy changed from a conventional oxygenation target (SpO2: ≥96%) to more conservative targets with permissive hypoxia (SpO2: 88-92% or PaO2: 60 mmHg) and hyperoxia avoidance (reduced oxygenation for Pa O 2 > 110   mmHg ). Patients were divided into a prechange group (April 2015 to March 2017; n = 83 ) and a postchange group (April 2017 to March 2019; n = 130 ). Data were extracted from clinical records and insurance claims. Using a multiple logistic regression model, we examined the association of the postchange group (permissive hypoxia and hyperoxia avoidance) with intensive care unit (ICU) mortality after adjusting for variables such as Sequential Organ Failure Assessment (SOFA) score and PaO2/FiO2 ratios. Results. The postchange group did not have significantly lower adjusted ICU mortality (0.67, 0.33-1.43; P = 0.31 ) relative to the prechange group. However, there were significant intergroup differences in mechanical ventilation duration (prechange: 11.0 days, postchange: 7.0 days; P = 0.01 ) and ICU stay (prechange: 11.0 days, postchange: 9.0 days; P = 0.02 ). Conclusions. Permissive hypoxia and hyperoxia avoidance had no significant association with reduced ICU mortality in mechanically ventilated septic patients. However, this approach was significantly associated with shorter mechanical ventilation duration and ICU stay, which can improve patient turnover and ventilator access.

Background: Acute type A aortic dissections have an extremely poor prognosis, and cardiac tamponade is a major cause of death in these patients. Here, we describe a case where congenital partial pericardial defect relieved cardiac tamponade caused by ruptured type A aortic dissection. Case presentation: A 79-year-old woman was hospitalized after experiencing chest pains and respiratory distress. She developed out-of-hospital cardiopulmonary arrest and was resuscitated with no sequelae 5 days before admission. Computed tomography confirmed pericardial and left pleural effusions, and type A aortic dissection was diagnosed. We began emergency ascending aortic replacement surgery under general anesthesia with propofol and remifentanil and incidentally discovered a congenital partial left-sided pericardial defect that allowed drainage of the hemopericardium and relieved cardiac tamponade. The surgery was successfully performed, and the patient recovered without complications. Conclusions: We experienced an extremely rare case where a congenital partial pericardial defect relieved cardiac tamponade associated with aortic dissection and contributed to the patient's survival.