Hypothermic cardiopulmonary bypass for minimally invasive mitral valve plasty in adult moyamoya disease

Anesthetic management in an adult moyamoya disease patient undergoing mitral valve plasty for severe mitral regurgitation

Background

Despite several previous reports, there are no established procedures for intraoperative management in moyamoya disease patients requiring cardiac surgery.

Case presentation

Herein, we report the case of a 42-year-old man who was scheduled to undergo mitral valve plasty for severe mitral regurgitation. He had been diagnosed with moyamoya disease on the onset of cerebral ischemia at 41 years of age. During the cardiac surgical procedure, the patient was maintained on inhalation anesthesia with 1 to 1.5 % sevoflurane. Sevoflurane causes cerebral vasodilation followed by increased cerebral blood flow, and moreover we expected a sevoflurane preconditioning-induced neuroprotective effect. In addition, we used pulsatile perfusion support to maintain cerebral circulation with intra-aortic balloon pumping during the cardiopulmonary bypass. We aimed to keep the mean arterial pressure constantly above 70 mmHg. We were able to maintain regional cerebral oxygen saturation at 80 % of the baseline value, and could not detect the progression of neurological deficits using follow-up brain single photon emission computed tomography. The patient was discharged 16 days after admission.

Conclusions

The details of the clinical course of his case will add to our knowledge regarding intraoperative management options in moyamoya disease patients requiring cardiac surgery. We suggest that pulsatile blood flow supported by intra-aortic balloon pumping and sevoflurane anesthesia for increasing cerebral blood flow and for possible neuroprotection may be efficacious for anesthetic management of moyamoya disease patients.

Deep hypothermic circulatory arrest for hemiarch replacement in a pediatric patient with moyamoya disease

Moyamoya disease is a chronic cerebrovascular occlusive disease, occurring predominantly in young populations, that causes cerebral ischemia and hemorrhage. Patients with moyamoya disease are at high risk of neurological complications during cardiac surgery because of perioperative hemodynamic changes. However, there is no established evidence on temperature management during cardiopulmonary bypass. Previous reports described normothermia or mild to moderate hypothermia during cardiopulmonary bypass in patients with moyamoya disease; however, surgical conditions, such as not having enough space to clamp the aorta or a clean surgical field, sometimes force us to use deep hypothermic circuratory arrest. We report a successful case of a pediatric patient with moyamoya disease who underwent deep hypothermic circulatory arrest (18 °C) for hemiarch replacement without neurological complications. Deep hypothermia may be an alternative technique for achieving cerebral protection in the context of moyamoya disease.