[Anesthesia management during coronary artery aneurysmectomy and tricuspid valvulectomy]

A 54-year-old man with infective tricuspid endocarditis and an infective right coronary artery aneurysm was scheduled for simultaneous coronary artery aneurysmectomy and tricuspid valvulectomy. However, the tricuspid valve replacement and annuloplasty procedures could not be performed because vegetation was noted on all his tricuspid leaflets. Moreover, the infective right coronary artery aneurysm was located proximal to the annulus of the tricuspid valve. Complications of tricuspid valvulectomy include tricuspid regurgitation, right ventricular capacity load and right ventricular pressure load. In the present case, after the patient was weaned from cardiopulmonary bypass (CPB), transesophageal echocardiography (TEE) revealed severe tricuspid regurgitation and shifting of the interventricular septum toward the left ventricle at the telediastolic stage. We managed this condition on the basis of the TEE findings with fluid therapy and a nitroglycerin vasoactive agonist, and adjusted the ventilator setting to reduce pulmonary vascular resistance. In the present case of infective tricuspid endocarditis with infective right coronary artery aneurysm, the selection of the appropriate surgical method was important. Moreover, respiratory management which did not increase pulmonary vascular resistance and adequate fluid management based on TEE findings after weaning from CPB were equally important during anesthesia for tricuspid valvulectomy.