Korean J Anesthesiol Case Reports Case 1 A 14-year old male had a past history of a total of three cardiac myxoma removal surgeries in the left atrium three years ago, in the right ventricle anterior papillary muscle and chordae two years ago, and in anterior mitral leaflet side of the left atrial wall, inferior atrial septum, and right ventricular outflow lateral aspect one year ago. He underwent a left orchiectomy for a sertoli cell tumor three years ago. He was diagnosed with Carney complex with the presence of adrenal mass, thyroid nodule, and pituitary adenoma, and was under ambulatory follow-up monitoring. The pre-operative echocardiography revealed a 20 × 20 mm mobile mass in the right ventricular outflow tract (Fig. 1 and 2). It also showed a coronary sinus dilatation (18 × 13 mm), and the ejection fraction was 59.8%. Hemiparesis developed after the cardiac myxoma removal surgery three years ago, but the patient recovered without any complications. Using sellar magnetic resonance imaging, a 17 mm pituitary adenoma and old multifocal cerebral infarctions in the cerebellum, brainstem, both occipital lobes, temporal lobes, parietal lobes, thalami, corpus callusum, left frontal lobe, and left basal ganglia were seen. The electrocardiography showed a normal sinus rhythm with nonspecific intraventricular block, and chest radiography showed no active lung lesions. For the pre-operative evaluation of the endocrine function, the department of endocrinology was consulted. A quadruple test was carried out by injecting growth hormone-releasing Kang and Kim hormone (GHRH), corticotrophin-releasing hormone (CRH), thyrotropic releasing hormone (TRH), and gonodotropin releasing hormone (GnRH). The results were normal responses to growth hormone (GH), thyroid stimulating hormone (TSH), follicle stimulating hormone (FSH), luteinizing hormone (LH), prolactin, and adrenocorticotropic hormone (ACTH). However a decreased response was seen to cortisol. Adrenal insufficiency was suspected, so on the morning of surgery 250 mg of hydrocortisone was injected intravenously. As premedication, 2 mg of midazolam and 0.2 mg of glycopyrrolate were intramuscularly injected and 20 mg of famotidine was intravenously injected. Physical examination revealed acromegaly due to the pituitary adenoma (height 191 cm, weight 104 kg) and the Mallampati class was 2. Pre- operative vital signs showed blood pressure at 120/80 mmHg and heart rate at 72 bpm. A left radial arterial line was placed before anesthetic induction. Electrocardiogram, pulse oxymeter, and arterial blood pressure were monitored while 120 mg of propofol and 300 μg of fentanyl were slowly injected intravenously. After adequate mask ventilation was confirmed, 50 mg of rocuronium was intravenously injected. Although the patient presented with a large tongue and long mandibular length due to acromegaly, the Cormack-Lehane grade was II and endotracheal intubation was not difficult. Expecting severe adhesions from the multiple numbers of myxoma removal surgeries, a large bore intravenous line as well as the central line was maintained and the cell saver was prepared as provisions for massive bleeding. Transesophageal echocardiography and nasopharyngeal temperature monitor were set. Anesthesia was maintained with sevoflurane at 1-2 vol%, fentanyl 400 μg per hour, and rocuronium. During the operation, vital signs were stable with blood pressure at 100-120/50-60 mmHg and heart Fig. 1. The pre-operative transthoracic echocardiogram of the patient from case 1 showed a 20 × 20 mm sized myxoma in the right ventricular outflow tract. M: cardiac myxoma, RV: right ventricle, IVS: interventricular septum, LV: left ventricle, LA: left atrium, PA: pulmonary artery. www.ekja.org Fig. 2. Pre-operative chest computed tomogram of the patient from case 1 showed a myxoma in the main pulmonary trunk. M: cardiac myxoma. 529