IntroductionThe possibility of hypercoagulability during the perioperative period of transcatheter aortic valve implantation (TAVI) has been noted; however, there is still a controversy regarding the appropriate perioperative antithrombotic therapy. The study investigated coagulation and platelet functions during the TAVI perioperative period using thromboelastography (TEG) 6s platelet mapping.MethodsA prospective observational study was conducted on 25 patients undergoing TAVI. TEG platelet mapping was performed at three time points: on admission to the operating room (before heparinisation), on postoperative day (POD) 1 and on POD 3. Perioperative changes observed included: maximum clot strength (MAHKH), clot strength without platelet function (MAActF), time to initiation of clots formation by coagulation factors (RHKH) and platelet function (Gp). Gpis activated by thrombin, and not affected by antiplatelet agents. It is calculated as [(5000×MAHKH)/(100 – MAHKH)] − [(5000×MAActF)/(100 – MAActF)]. Finally, MAADP/AAand GADP/AA, which reflect clot strength and platelet aggregation mediated by ADP/thromboxane A2receptors, respectively, were also examined using the same method as for Gp.ResultsMAHKHcontinued to decrease until POD 3, indicating antithrombotic change after TAVI. Gpcontinuously decreased for 3 days after TAVI, while MAActFincreased significantly on POD 3. Furthermore, RHKHshortened on POD 1 and POD 3, suggesting increased coagulation capacity after TAVI. Finally, GADPin clopidogrel-naive patients was reduced for 3 days after TAVI, while GAAin aspirin-naive patients showed no significant change perioperatively.ConclusionsIn this study involving TEG platelet mapping, coagulation capacity increased while platelet function decreased, resulting in antithrombotic change for 3 days after TAVI. The ADP receptor system may be implicated in the decreased platelet function. These results may be useful for considering optimal perioperative antithrombotic therapy in TAVI.

Saline contrast echocardiography requires an adequate provocation method for the detection of patent foramen ovale. The party balloon inflation maneuver during saline contrast transthoracic echocardiography is easy to explain to patients and objectively assesses the performance of provocative maneuvers by a clinician by watching balloon inflation. ( Level of Difficulty: Intermediate. )

Background A right-to-left shunt via a patent foramen ovale (PFO) during off-pump coronary artery bypass (OPCAB) may result in difficulties in oxygenation and circulatory management. We herein present a case of a marked shunt via a PFO during OPCAB. Case presentation A 74-year-old man who had aortic root enlargement, compressing the right atrium, and an atrial septal aneurysm, underwent OPCAB. When the heart was fixed for the anastomosis of the left anterior descending artery, sudden hypoxemia and hypotension were observed. Intraoperative transesophageal echocardiography (TEE) showed a right-to-left shunt via a PFO that was unnoticed preoperatively. After the anastomosis was completed, TEE revealed no shunt through the PFO. Conclusions We should check for a PFO in case of an atrial septal aneurysm. Compression of the right atrium is considered an important anatomical risk of the right-to-left shunt in OPCAB.

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