[Vascular Prosthesis Perforation Caused by a Stent Graft Inserted into the Innominate Artery after Total Aortic Arch Replacement].

The patient was a 60-year-old woman who underwent thoracoabdominal aorta replacement for type B aortic dissection three years ago and aortic root replacement and total aortic arch replacement due to asymptomatic type A aortic dissection two years previously. Her clinical course was uneventful until follow-up computed tomography (CT) disclosed anastomotic insufficiency in the innominate artery and left main coronary artery stenosis owing to hematoma. Emergent percutaneous coronary intervention and stent graft insertion into the innominate artery were performed successfully. Seven months later, however, CT scan revealed a perforation in the posterior wall of the artificial graft damaged by the edge of the implanted stent graft. The patient underwent open surgery and perforation of artificial graft was sutured and redundant stent graft edge was resected. Artificial graft damage by stent graft placement is rare to date, but may increase in the future in accordance with broader application of endovascular treatment.

Analysis of gender-based differences among surgeons in Japan: results of a survey conducted by the Japan Surgical Society. Part. 2: personal life.

PURPOSE: To assess the true conditions and perceptions of the personal lives of men and women working as surgeons in Japan. METHODS: In 2014, all e-mail subscribed members of the Japan Surgical Society (JSS, n = 29,861) were invited to complete a web-based survey. The questions covered demographic information, work environment, and personal life (including marital status, childcare, and nursing care for adult family members). RESULTS: In total, 6211 surgeons (5586 men and 625 women) returned the questionnaires, representing a response rate of 20.8%. Based on the questionnaire responses, surgeons generally prioritize work and spend most of their time at work, although women with children prioritize their family over work; men spend significantly fewer hours on domestic work/childcare than do their female counterparts (men 0.76 h/day vs. women 2.93 h/day, p < 0.01); and both men and women surgeons, regardless of their age or whether they have children, place more importance on the role of women in the family. CONCLUSIONS: The personal lives of Japanese surgeons differed significantly according to gender and whether they have children. The conservative idea that women should bear primary responsibility for the family still pertains for both men and women working as surgeons in Japan.

Analysis of gender-based differences among surgeons in Japan: results of a survey conducted by the Japan Surgical Society. Part 1: Working style.

PURPOSE: To assess the working styles of men and women working as surgeons in Japan. METHODS: In July, 2014, the Japan Surgical Society invited all their members (n = 29,861), through an internet campaign, to participate in a nationwide survey of surgeons. The items investigated in this descriptive study included demographic information and working styles, based on a questionnaire. RESULTS: In total, 6211 surgeons participated (response rate 20.8%, 5586 men and 625 women). The largest age stratum was 40-49 years for men and 30-39 years for women. Overall, respondents identified their labor contract, including salary and work hours, as the highest priority for improvement. Women with children were more likely to be part-time employees, work fewer hours, and take fewer house calls/on-calls than their male counterparts. Moreover, women of all ages earned a lower annual income than men, irrespective of whether they had children. Perception scores for discrimination related to work and promotion were significantly higher among women than men (p < 0.01 and p = 0.011, respectively). CONCLUSIONS: A significant difference in working style was observed between men and women working as surgeons in Japan.

Japanese Multicenter Outcomes With the HeartMate II Left Ventricular Assist Device in Patients With Small Body Surface Area.

BACKGROUND: The HeartMate II (HMII) continuous-flow LVAD was approved for Japanese health insurance coverage in April 2013 as a bridge to transplantation (BTT). We report on post-approval Japanese multicenter outcomes, and a comparison between patients with low and high body surface area (BSA). METHODS AND RESULTS: HMII LVAD was implanted in 104 consecutive patients at 15 Japanese centers between April 2013 and July 2014. Perioperative data were submitted to the Japanese Registry for Mechanically Assisted Circulatory Support. Patients were divided into 2 groups on the basis of BSA less or greater than 1.5 m(2). Survival outcomes, New York Heart Association functional class, and adverse event rates were compared between the 2 groups. Preoperative hemodynamics and INTERMACS profiles were similar between groups. There were more females and younger patients in the low BSA group. The respective 6-month and 1-year death- or pump exchange-free survival rates were excellent: 90% and 90% in the BSA <1.5 group vs. 90% and 85% in the BSA ≥1.5 group. In the BSA <1.5 group, occurrence of hemorrhagic stroke was 10% and occurrence of embolic stroke was 0%, vs. 12% and 8% in BSA ≥1.5 group. Driveline infection was encountered more frequently in the BSA <1.5 group. CONCLUSIONS: Results for HMII LVAD as BTT in the post-approval era showed excellent survival and functional capacity improvement. Of particular interest to the Japanese patient population are the excellent results in patients with small BSA. (Circ J 2016; 80: 1931-1936).

Jarvik 2000 axial-flow ventricular assist device placement to a systemic morphologic right ventricle in congenitally corrected transposition of the great arteries.

Few descriptions of the implantation and management of an implantable ventricular assist device in patients with complex congenital heart disease exist in the literature. The Jarvik 2000 axial-flow ventricular assist device (Jarvik Heart, Inc., NYC, NY, USA) can be placed in either the left or the right ventricle. We present the case of a 60-year-old man with congenitally corrected transposition of the great arteries who underwent successful placement of a Jarvik 2000 axial-flow ventricular assist device in a systemic morphologic right ventricle.

Preliminary report on the cost effectiveness of ventricular assist devices.

The aim of the present study was to perform a cost-effectiveness analysis (CEA) of ventricular assist devices (VAD) implantation surgery in the Japanese medical reimbursement system. The study group consisted of thirty-seven patients who had undergone VAD implantation surgery for dilated cardiomyopathy (n = 25; 67.6 %) or hypertrophic cardiomyopathy (n = 4; 10.8 %), and others (n = 8; 21.6 %). Quality-adjusted life years (QALYs) were calculated using the utility score and years of life. Medical reimbursement bills were chosen as cost indices. The observation period was the 12-month period after surgery. Then, the incremental cost-effectiveness ratio was calculated according to the VAD type. In addition, the prognosis after 36 months was estimated on the basis of the results obtained using the Markov chain model. The mean preoperative INTERMACS profile score was 2.35 ± 0.77. Our results showed that the utility score, which indicates the effectiveness of VAD implantation surgery, improved by 0.279 ± 0.188 (ΔQALY, p < 0.05). The cost of VAD implantation surgery was 313,282 ± 25,275 (ΔUS$/year) on the basis of medical reimbursement bills associated with therapeutic interventions. The calculated result of CEA was 364,501 ± 190,599 (ΔUS$/QALY). The improvement in the utility score was greater for implantable versus extracorporeal VADs (0.233 ± 0.534 vs. 0.371 ± 0.238) and ICER was 303,104 (ΔUS$/ΔQALY). Furthermore, when we estimated CEA for 36 months, the expected baseline value was 102,712 (US$/QALY). Therefore, VAD implantation surgery was cost effective considering the disease specificities.

Long-term results after treatment of the ascending aorta for bicuspid aortic valve patients.

PURPOSE: We evaluated the long-term results of aortic valve replacement for bicuspid aortic valve patients with or without surgical treatment of the ascending aorta. METHODS: A total of 145 bicuspid aortic valve patients had undergone aortic valve replacement since 1974 at our institution. No surgical treatment (Group-N; n = 115) was performed in the ascending aorta if the diameter was less than 40 mm. We wrapped an ascending aorta of 40-50 mm with an artificial graft (Group-W; n = 19), and performed replacement (Group-R; n = 11) if the ascending aorta measured more than 50 mm. Follow-up was completed for 144 patients (99.3 % of the cases). RESULTS: The hospital mortality rate was 1.4 %. There were no significant differences among Groups N, W and R in the freedom from valve-related death and cardiac death at 10 years after surgery. The rates of freedom from aorta-related events in the three groups at 10 years after surgery were 98.3 % (Group-N), 100 % (Group-W) and 100 % (Group-R). CONCLUSIONS: The long-term survival was equivalent among the three groups, and the rates of freedom from aorta-related death or events were low. Our surgical protocol for the treatment of the enlarged ascending aorta associated with BAV is appropriate.

Autophagy-mediated stress response in motor neurons after hypothermic spinal cord ischemia in rabbits.

OBJECTIVE: The development of spinal cord injury is believed to be related to the vulnerability of spinal motor neurons to ischemia. However, the mechanisms underlying this vulnerability have not been fully investigated. Previously, we reported that spinal motor neurons are lost likely due to autophagy and that local hypothermia prevents such spinal motor neuron death. Therefore, we investigated the role of autophagy in normothermic and hypothermic spinal cord ischemia using an immunohistochemical analysis of Beclin 1 (BCLN1; B-cell leukemia 2 protein [Bcl-2] interacting protein), Bcl-2, and γ-aminobutyric acid type-A receptor-associated protein (GABARAP), which are considered autophagy-related proteins. METHODS: We used rabbit normothermic and hypothermic transient spinal cord ischemia models using a balloon catheter. Neurologic function was assessed according to the Johnson score, and the spinal cord was removed at 8 hours and 1, 2, and 7 days after reperfusion, and morphologic changes were examined using hematoxylin and eosin staining. A Western blot analysis and histochemical study of BCLN1, Bcl-2, and GABARAP, and double-labeled fluorescent immunocytochemical studies were performed. RESULTS: There were significant differences in the physiologic function between the normothermic model and hypothermic model after the procedure (P < .05). In the normothermic model, most of the motor neurons were selectively lost at 7 days of reperfusion (P < .001 compared with the sham group), and they were preserved in the hypothermic model (P = .574 compared with the sham group). The Western blot analysis revealed that the sustained expression of the autophagy markers, BCLN1 and GABARAP, was observed (P < .001 compared with the sham group) and was associated with neuronal cell death in normothermic ischemic conditions. In hypothermic ischemic conditions, the autophagy inhibitory protein Bcl-2 was powerfully induced (P < .001 compared with the sham group) and was associated with blunted expression of BCLN1 and GABARAP and neuronal cell survival. The double-label fluorescent immunocytochemical study revealed that immunoreactivitiy for BCLN1, Bcl-2, and GABARAP was induced in the same motor neurons. CONCLUSIONS: These data suggest that the prolonged induction of autophagy might be a potential factor responsible for delayed motor neuron death, and the induction of the autophagy inhibitory protein Bcl-2 using hypothermia might limit autophagy and protect against delayed motor neuron death.

Long-Term Comparison of Three Types of Aortic St. Jude Medical Mechanical Prosthesis in Japanese Patients.

BACKGROUND: The long-term results achieved with aortic St. Jude Medical (SJM) mechanical prostheses in various age groups of Japanese patients have not been previously compared or reported. METHODS AND RESULTS: Since 1981, a total of 240 SJM valves were implanted in 79 patients using the Standard model, in 58 patients with the Hemodynamic Plus model, and in 103 patients with the Regent model for aortic valve replacement (AVR). Follow-up was completed for 2,397 patient-years in 97.5% of the patients, among whom the effect of age was compared, and the subjects were divided into younger (<65 years) and older (≥65 years) groups. Hospital mortality rate was 2.5%. No structural valve deterioration was observed during the follow-up period. In addition, no significant differences were observed in long-term survival between the 3 models. In contrast, significantly better rates of freedom from all-cause death (P<0.0001), valve-related death (P=0.0018) and valve-related morbidity (P=0.0021), including bleeding events (P=0.0007), were observed in the younger group (n=157, 50.6±1.0 years old) than in the older group (n=83, 72.5±0.7 years old). CONCLUSIONS: All types of SJM valve used for single AVR achieved satisfactory early and long-term results in each age group even 25 years after surgery. When selecting this prosthesis for elderly patients, however, relatively worse performance may be expected compared with that observed in younger patients.

[Treatment for the Postinfarction Ventricular Defect].

Postinfarction ventricular septal defect (PIVSD) is uncommon but serious disease which normally required emergent surgery. Due to the severe hemodynamic condition of this disease, operative results are still poor even after the exclusion method was introduced by David and Komeda in 1990. In fact, the annual report in 2012 of General Thoracic Cardiovascular Surgery reported that the hospital mortality of the acute PIVSD was 26.7%. Percutaneous closure of PIVSD using the Amplatzer PIVSD device may be a reasonably effective treatment for the extremely poor-risk patients.

Long-term results of aortic valve replacement with mechanical prosthesis or carpentier-edwards perimount bioprosthesis in Japanese patients according to age.

BACKGROUND: The long-term results of aortic valve replacement (AVR; n=737) with bileaflet mechanical prosthesis (MP) or Carpentier-Edwards Perimount bioprostheses (BP) were evaluated in different age groups. METHODS AND RESULTS: Since 1981, a total of 737 prostheses (424 bileaflet MP vs. 313 BP) were implanted for AVR in 278 patients aged ≥70 years (79 MP vs. 199 BP), in 191 patients aged 60-69 years (128 MP vs. 63 BP) and in 268 patients aged <60 years (217 MP vs. 51 BP). Follow-up was completed for 6,523 patient-years in 98.5% of cases. Among the patients ≥70 years, both the actuarial survival rate (P=0.0434) and freedom from valve-related morbidity (P=0.0205) were better in the BP group than in the MP group without any difference in occurrence of structural valve deterioration in both groups. Among the patients aged 60-69, anticoagulant-related complications occurred less often in the BP group (P=0.0134) without any difference in long-term survival. Among the patients aged <60, long-term survival was significantly better in the MP group, whereas freedom from anticoagulant-related events did not differ. CONCLUSIONS: The use of BP is suitable in patients aged ≥70 years, while the use of bileaflet MP is preferable in patients aged <60 years. Among patients aged 60-69 years, the use of BP is acceptable because of the lower incidence of anticoagulant-related events and the equivalent long-term survival.

Cardiac energetics analysis after aortic valve replacement with 16-mm ATS mechanical valve.

The 16-mm ATS mechanical valve is one of the smallest prosthetic valves used for aortic valve replacement (AVR) in patients with a very small aortic annulus, and its clinical outcomes are reportedly satisfactory. Here, we analyzed the left ventricular (LV) performance after AVR with the 16-mm ATS mechanical valve, based on the concept of cardiac energetics analysis. Eleven patients who underwent AVR with the 16-mm ATS mechanical valve were enrolled in this study. All underwent echocardiographic examination at three time points: before AVR, approximately 1 month after AVR, and approximately 1 year after AVR. LV contractility (end-systolic elastance [Ees]), afterload (effective arterial elastance [Ea]), and efficiency (ventriculoarterial coupling [Ea/Ees] and the stroke work to pressure-volume area ratio [SW/PVA]) were noninvasively measured by echocardiographic data and blood pressure measurement. Ees transiently decreased after AVR and then recovered to the pre-AVR level at the one-year follow-up. Ea significantly decreased in a stepwise manner. Consequently, Ea/Ees and SW/PVA were also significantly improved at the one-year follow-up compared with those before AVR. The midterm LV performance after AVR with the 16-mm ATS mechanical valve was satisfactory. AVR with the 16-mm ATS mechanical valve is validated as an effective treatment for patients with a very small aortic annulus. The cardiac energetics variables, coupling with the conventional hemodynamic variables, can contribute to a better understanding of the patients' clinical conditions, and those may serve as promising indices of the cardiac function.

Operative modification for the prevention of device-related infection during NIPRO extracorporeal left ventricular assist device implantation.

An operative modification in which the NIPRO left ventricular assist device (LVAD) cannulas are passed through the intraperitoneal cavity is performed as the first-choice standard technique in our institution. Eighteen consecutive patients who underwent NIPRO LVAD implantation as heart transplantation candidates were enrolled in this study. The cannulas were passed through the intraperitoneal cavity in 11 patients (Group IP) and the extraperitoneal space in 7 patients (Group EP). A device-related major infection was defined as bloodstream infection and/or abscess formation in the deep tissue space. Device-related major infection occurred in 6 patients in Group IP and in 6 patients in Group EP. Of these patients, 3 patients in Group IP and 5 patients in Group EP suffered from uncontrollable bloodstream infection and finally died of development into multiple organ failure and/or cerebrovascular accidents. The actuarial rates of freedom from device-related major infection at 6 months after LVAD implantation were 100 % in Group IP and 38 % in Group EP, respectively (p = 0.02). Moreover, the actuarial survival rates after the initial device-related major infection in Group IP could be significantly higher than in Group EP (83 and 67 % at 6 months, p = 0.03). We demonstrated that this operative modification can contribute to prevention of progression of superficial skin infection to critical infection and to extension of the survival duration after the initial device-related major infection.

Results of the prospective multicenter Japanese bridge to transplant study with a continuous-flow left ventricular assist device.

Continuous-flow left ventricular assist devices (LVADs) are becoming the standard of care for patients with refractory end-stage heart failure. We present the outcomes of patients enrolled in a prospective multicenter clinical study in Japan using the HeartMate II continuous-flow LVAD for bridge to transplantation. The study evaluated 6 inotrope-dependent heart failure patients failing on medical management (3 males and 3 females, age 44.7 ± 15.8 years, BSA 1.58 ± 0.17 m(2)) implanted with the HMII LVAD at 5 Japanese centers. Functional status, adverse events and outcomes were determined for the first 6 months with follow-up at 2 years. After implant, functional improvement was evident in 6-min walk distance which increased from 268 ± 92 m at baseline to 399 ± 105 m at 6 months, and 100% of patients were in NYHA class I or II at 6 months compared to 0% at baseline. Adverse events included localized non-device-related infection (4/6), arrhythmias (3/6) and percutaneous lead infection (1/6). There were no re-thoracotomies for bleeding and no strokes or pump replacements. All patients were alive at 6 months and all were transplanted after 1.96-3.58 years of LVAD support. The results in Japan of the HMII LVAD for BTT are consistent with results from the US pivotal clinical trial. The expanded use of this technology to Japanese heart failure patients is appropriate.

[Intraaortic balloon pumping( IABP) in Japan].

The intraaortic balloon pumping (IABP) is the most widely used circulatory assist device. IABP increases coronary perfusion in diastolic phase by the inflation of the balloon in the descending aorta (diastolic augmentation) and reduces afterload in systolic phase by the deflation of the balloon( systolic unloading). IABP improves the hemodynamic condition of patients who fall into acute heart failure and/or cardiogenic shock. Six-type IABP system can be used in Japan. The IABP-SHOCK II trial shows that there is no significant difference in mortality between optimal medical treatment with IABP and without IABP in addition to early revascularization. Clinical backgrounds in Japan are different from those in IABP-SHOCK II trial, and the further prospective studies of IABP in Japan thus called for.

A case of conversion of a NIPRO ventricular assist system to an EVAHEART left ventricular assist system.

Bridge to bridge (BTB) is a promising strategy for the treatment of end-stage heart failure that involves the left ventricular assist system (LVAS). We describe our experience with the conversion of an extracorporeal ventricular assist system (VAS), the NIPRO VAS, to an implantable LVAS, the EVAHEART LVAS. A 32-year-old man underwent a NIPRO VAS implantation as a bridge to decision for a condition consistent with Interagency Registry for Mechanically Assisted Circulatory Support profile 1. He was later diagnosed with secondary cardiomyopathy due to cardiac sarcoidosis. During the period in which he had NIPRO VAS support, no significant bacterial cultures were obtained from the cannula-piercing site, and no systemic infection occurred. Approximately 5 months after the NIPRO VAS implantation, he underwent an EVAHEART LVAS implantation as a BTB. The procedure required technical modifications, including the anastomosis of outflow grafts, trimming of the apical cuff, and creation of a pump pocket. The operation was completed uneventfully. The patient completed the discharge program for awaiting heart transplantation at home. Approximately 6 months after the EVAHEART LVAS implantation, he continues to do well without any complications, including infection, and visits our hospital as an outpatient. Conversion to an implantable LVAS can be beneficial in carefully selected patients after ascertaining the operative indications and operation timing.

Left ventricular performance after aortic valve replacement in patients with low ejection fraction.

The operative validity of aortic valve replacement (AVR) for high-risk patients with impaired left ventricular (LV) function is controversial. We measured LV contractility, afterload, and efficiency by use of transthoracic echocardiography data obtained before, after, and approximately 1 year after isolated AVR for 335 patients with aortic stenosis (AS group; n = 160), aortic regurgitation (AR group; n = 116), or aortic stenosis and regurgitation (ASR group; n = 59). Two subgroups were created: LV ejection fraction (EF) of ≥50 % (normal-EF subgroup) and <50 % (low-EF subgroup). Contractility decreased after AVR in the normal-EF AS and normal-EF AR subgroups, but did not change after AVR in the low-EF subgroups. Afterload decreased after AVR in the AS group and increased in the AR group. LV efficiency was unchanged after AVR in the normal-EF AS and ASR subgroups, worsened in the normal-EF AR subgroup, improved in the low-EF AS and ASR subgroups, and did not improve in the low-EF AR subgroup. LV contractility and efficiency improved during the 1-year period after AVR for all patients and subgroups, but the improvements in the low-EF AR subgroup were not as good as those in the low-EF AS and ASR subgroups. Improvements in LV contractility and efficiency after AVR can be expected for patients with low EF. However, contractility and efficiency did not improve after AVR for patients with AR and low EF. Low mortality and morbidity of AVR likely conceal a latent problem among patients with AR.

Report from the Committee for Improving the Work Environment of Japanese Surgeons: survey on effects of the fee revision for medical services provided by surgeons.

PURPOSE: The aim of this study was to achieve improvements in the work environment of Japanese surgeons and shortage of surgeons. METHODS: Questionnaires were distributed to selected Japanese surgical Society (JSS) members. Retrospective analysis was conducted comparing the current 2011 survey with previous 2007 survey. To examine the influence of 2010 revision of the fee for medical services performed by surgeons, we distributed a second questionnaire to directors of hospitals and administrators of clerks belonging to official institutes in JSS. Collective data were analyzed retrospectively. RESULTS: The main potential causes for the shortage of surgeons in Japan were long hours (72.8 %), excessive emergency surgeries (69.4 %), and high risk of lawsuit (67.7 %). Mean weekly working hours of surgeons in national or public university hospitals and private university hospitals were 96.2 and 85.6, respectively. Approximately 70 % of surgeons were forced to do hardworking tasks, possibly leading to death from overwork. Of note, approximately 25 % of surgeons had over time of more than 100 h a week, coinciding to the number of hours that might lead to death from fatigue, described in the Japanese labor law. Although the total medical service fee in hospitals, especially in large-scale hospitals with more than 500 beds, increased markedly after 2010 revision of the fee for medical services performed by surgeons, few hospitals gave perquisites and/or incentives to surgeons. CONCLUSION: To prevent and avoid collapse of the surgical specialty in Japan, an improvement in the work environment of surgeons by initiation of the JSS would be required as soon as possible.

[Donor heart preservation with University of Wisconsin solution and immunosuppressive therapy with drip-infusion of tacrolimus].

Clinical approach for heart transplantation in Kyushu University Hospital Heart Center about donor heart preservation and immunosuppressive therapy is reviewed. University of Wisconsin solution has been used for donor heart preservation as the 1st-line solution, because left ventricular function after both 6-hour and 24-hour preservation with University of Wisconsin solution was superior to that with Celsior solution on the cross-circulated rabbit heart preparation model. Donor hearts are arrested by the extracellular-type cardioplegia to prevent coronary vasoconstriction associated with preservation in University of Wisconsin solution. Tacrolimus has been used as immunosuppressive agent. Drip-infusion of tacrolimus (0.02 mg/kg per day) is started immediately after heart transplantation aiming at definitive blood level control.

[Development of hemostatic sealant for arterial anastomosis; clinical application].

For the purpose of examining the clinical applicability of a newly developed surgical sealant, animal experiments were performed, and clinical trial was followed. In animal experiments, several animal models, including carotid artery anastomosis model and coronary artery bypass grafting model were undertaken. In each model, complete hemostasis of the anastomoses using four simple interrupted sutures, was obtained. In addition, elastomeric property of the sealant prevented thinning of the arterial wall. The clinical trial performed in patients with thoracic aortic surgery showed significantly better hemostasis even under heparinized condition. Based on these excellent results, clinical usage of the sealant was approved.