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Background: A review committee for unapproved and off-label drugs with high medical needs determined that the indication of fibrinogen concentrate for cardiovascular surgery would be publicly acceptable in 2021. However, the Japanese Society of Cardiovascular Surgery is required the conduct of several surveys demonstrating that fibrinogen concentrate can be used properly in medical settings. A questionnaire concerning the use of fibrinogen concentrate in cardiovascular surgery was one such required survey. Methods: A questionnaire concerning the use of fibrinogen concentrate was conducted in December 2021 at 551 certified training facilities of the Japanese Board of Cardiovascular Surgery, and responses were received from 375 facilities (68%). Results: Fibrinogen concentrate was used in 98 centers (26%). Aortic surgery (thoracic/thoracoabdominal) (50%) and cardiac redo surgery (24%) were eligible common surgeries requiring fibrinogen concentrate, and the intraoperative measurement of fibrinogen levels was performed in 77% of centers. The triggers for the use of fibrinogen concentrate were a fibrinogen level <150 mg/dl in 30%, <100 mg/dl in 20% and massive bleeding tendency in 40%. Of note, only 39 facilities (10%) were able to prepare cryoprecipitate in-hospital, and 34 centers (9%) used it for cardiovascular surgery. One hundred and seven centers (29%) planned to apply for facility accreditation for the use of fibrinogen concentrate, and 40 facilities (10%) answered that they would decide based on the situation. The expected number of annual cases in which fibrinogen concentrate would be used for cardiovascular surgery reached 4,860 cases: <10 cases in 52 centers, 10-19 cases in 50 centers, 20-49 cases in 31 centers, 50-99 cases in 12 centers and ≥100 cases in 2 centers. Conclusion: We conducted a questionnaire on the use of fibrinogen concentrate. Intraoperative fibrinogen level measurement was performed at approximately 80% of institutions, and the annual number of cases likely to use fibrinogen concentrate was predicted to reach about 5,000 cases. However, only 10% of centers used cryoprecipitates prepared in-hospital.
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The purpose of this study is to assess the impact of coronavirus disease 2019 (COVID-19) on the performance of cardiovascular surgery in Japan. The information gathered may be useful to prepare for a surgery in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) positive patients and prevent COVID-19 transmission from surgical patients to healthcare workers. [Methods] A web-based questionnaire was distributed to all accredited cardiovascular surgery centers in Japan. A total of 550 questionnaires were sent, and 310 (56.4%) were returned. [Results] Preoperative PCR or antigen testing was performed in all patients at 68.8% of centers. The proportion of surgeries postponed or cancelled was the highest for elective valvular and aortic surgeries and for emergency aortic surgeries. In most facilities elective surgeries were restricted to less than 50% of usual case volumes, while approximately 40% did not experience any negative impact on the case volume. Among the surgical patients, 32 were suspected to be SARS-CoV-2 positive, and 10 were confirmed. As preventive measures against spreading infection, more than 90% of the patients wore N95 masks, 33.3% full PPE, and 66.7% N95 mask+face shield. No case of patient-to-healthcare-worker transmission was reported. There were no postoperative deaths among the confirmed SARS-CoV-2 patients. [Conclusion] Restriction of surgical practice was placed on many institutions in the COVID-19 pandemic, but the degree of restrictions varied. Preoperative screening of all surgical patients and intraoperative use of PPE in those with suspected or confirmed SARS-CoV-2 infection adequately prevented transmission to healthcare workers. Since COVID-19 has a nationwide impact, it is important to continuously monitor surgical outcomes and infection rate by conducting perioperative surveys of COVID-19 patients.
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A 57-year-old man complained of dyspnea, and his echocardiography showed diffuse severe left ventricular dysfunction. Five days after admission and starting the treatment for congestive heart failure, a computed tomography pointed out DeBakey type 1 aortic dissection with a patent false lumen incidentally. The ostium of the left coronary artery was compressed with the false lumen, and this finding was thought to be a cause of development of left ventricular dysfunction. A modified Bentall procedure with bioprosthesis and total arch replacement were performed. The patient was discharged on the 28th postoperative day without any complications.
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A recent fatal accident related to the use of the pulmonary artery catheter (PAC) promoted us to conduct a questionnaire survey to assess the current use of the PAC and its complications during cardiac surgery. Methods : A 10-item questionnaire was distributed to all board-certified cardiovascular surgery centers in Japan. Five hundred thirty-two questionnaires were distributed and 325 (61.1%) were returned. Results : Seventy-two percents of hospitals used the PAC in more than 90% of cases, while only 17% used it less than 50% of the time. Indication of its use was not clearly determined in 52% of hospitals. Entrapment of the PAC was experienced in 28% of centers in the last 10 years, and its incidence was calculated as 0.07%. At a quarter of hospitals, checking for PAC to confirm absence of entrapment was not performed during the operation. Pulmonary artery rupture occurred at 22% of hospitals, and its incidence was 0.05%. Agreements on handling PAC to prevent cardiac injury or pulmonary artery rupture were not made in 24 and 56% of hospitals respectively. Conclusion : These data demonstrate that in many of the cardiac surgery centers in Japan, the PAC is still routinely used. Serious complications including catheter entrapment and pulmonary artery injury were encountered in a substantial number of patients. Development of guidelines for PAC during cardiac surgery to limit its use to patients with clear benefits and prevent related complications is warranted.
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Purpose : Recently, the Japanese government has promoted reform of working practices. The working environment of medical professionals was no exception. In the present study, we investigated the current working environment and issues of cardiovascular surgeons, who are supposed to be working in one of the most demanding circumstances in Japan. Methods : In December 2018, the Japanese Society for Cardiovascular Surgery (JSCVS) sent a questionnaire to all JSCVS members via the internet to obtain basic data on the working environment including working hours, working items, income, and the issues to be solved for cardiovascular surgeons in Japan. Results : The JSCVS received responses from 634 cardiovascular surgeons (response rate 17%, 589 males/38 females). Respondents were primarily mid-career surgeons in their age of 40 s and 50 s. Four hundred seventy-three respondents (75.5%) and 176 respondents (28.2%) answered that they worked an average of 60 and 80 h a week, respectively. In addition, 249 respondents (40.4%) reported receiving no allowance for on-call work during off hours, after midnight, or on a holiday, while 345 respondents (56.6%) reported receiving no allowance for emergency surgery during off hours, after midnight, or on a holiday. Conclusion : Over 75% of cardiovascular surgeons reported being overworked without receiving an appropriate amount of income. Along with the reform of working style being made for the Japanese people, improving the working environment of cardiovascular surgeons is also an urgent matter to maintain healthcare for cardiovascular disease. Facilitating understanding of the issue by the Japanese people is of the utmost importance for the JSCVS.
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Retrograde type A aortic dissection (RTAD) following thoracic endovascular aortic repair (TEVAR) is a lethal complication. A 54-year-old woman with bovine aortic arch presented with dilatation of the descending aorta due to chronic type B aortic dissection. She underwent TEVAR in zone 2 for closure of the entry site just below the origin of the left subclavian artery. On the day after TEAVR, she showed right hemiparesis, and was diagnosed with cerebral infarction on MRI and RTAD on CT. She underwent an emergent operation. The entry was at the proximal end of the bovine trunk, where the edge of the bare stent stuck out. We performed partial arch replacement with entry resection. Her postoperative course was uneventful. She was transferred to another hospital for rehabilitation 37 days after the surgery.
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<p><b>Objectives</b> : Many reports have investigated the work environment of physicians and reported the association between work environment, burnout, and the quality of medical care. We aimed to determine the key to improving the work environment by analyzing the results of a Japanese survey for young cardiovascular surgeons. <b>Methods</b> : A survey on work environment was performed among the young members of The Japanese Society for Cardiovascular Surgery (≤40 years of age) to measure their job satisfaction for 9 items : operation, perioperative work, number of hours working or sleeping, board affairs (application or renewal of board certification), motivation, salary, days off, quality of life, and mental status. Univariate and multivariate analyses using 16 factors for the work environment (age, number of years in practice, gender, subspecialty, board certification in surgery, board certification in cardiovascular surgery, primary practice hospital, workdays and nights on duty in a primary practice setting, workdays and nights on duty outside primary practice, total annual income, overtime work hours, overtime entitlement, gap in overtime work and entitlement, and presence of an intensive care unit [ICU] managed by ICU physicians) were performed to identify the risk factors for dissatisfaction. <b>Results</b> : The survey was completed by 327 of 1,304 (25.1% response rate) young members of the Japanese Society for Cardiovascular Surgery. The respondents had an average of 8.5±3.5 years in practice, and 292 (89.3%) respondents were male. Only 14.2% of the responding young surgeons reported no dissatisfaction in any items. In all items, the young surgeons were most satisfied with operation (34.6% of all responders). Age, years in practice, female gender, board certification in surgery, working at a university hospital, workdays in a primary practice setting, and workdays outside a primary practice setting were identified as significant factors for dissatisfaction, while a subspecialty in vascular surgery, total annual income, board certification in cardiovascular surgery, and the presence of an ICU managed by ICU physicians were identified as significant factors against dissatisfaction in the work environment. <b>Conclusions</b> : Our analyses of the survey results identified a number of risk factors for dissatisfaction in the work environment among young cardiovascular surgeons. Regarding the quality of medical care, respondents hoped for a reduced burden on surgeons and the establishment of a work-shift system in the cardiovascular department and an interdisciplinary team including an ICU physician. Multidimensional analyses including job satisfaction, rewards as training, and a quantitative evaluation of the quality of medical care will be necessary to clarify the corresponding relationship between consumers and providers of cardiovascular surgery in the work environment.</p>
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<p>A 42 year-old woman with Marfan syndrome, who had replacement of the ascending aorta for acute aortic dissection several years ago, was found to have distal aortic arch aneurysm. The aneurysm had small entries at cervical arterial branches and large re-entry at the left external iliac artery. It was necessary to perform two-staged operation Bentall procedure with total arch replacement and abdominal aortic replacement with re-entry closure. It was usually performed with a primary entry closure for chronic aortic dissection, but massive invasion was expected. We performed catheter angiography for entry and re-entry, and decided to perform preceding re-entry closure. First, we underwent replacement of the abdominal aorta, and then successfully performed the Bentall procedure with total aortic arch replacement. The catheter angiography was useful for decision-making for medical treatment.</p>
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<p>Thirty two years-old man with arthralgia in both hands was given with non-steroid anti-inflammatory drug and followed. The symptoms persisted, and hematuria and signs of infection were getting apparent. The patient was referred to our hospital with increasing dyspnea. The patient presented acute heart failure, acute renal insufficiency and respiratory failure. Echocardiography revealed vegetation and regurgitation in the aortic and mitral valve. Blood culture demonstrated α-<i>Streptococcus</i>. CT revealed enlargement of the aortic root. The patient was diagnosed with infectious endocarditis, and referred for surgery. At surgery, the aortic valve and mitral valve were severely destroyed. Aortic root and mitral valve replacement were performed. Pathological findings demonstrated valve destruction as a result of endocarditis due to active rheumatic fever. Clumps of bacteria were not noted around the valves. This is a rare adult case with valve destruction by acute rheumatic fever.</p>
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<p> The education program in all medical schools in Japan has been studied and analyzed every 2 years since 1974 by the curriculum committee of the Association of Japan Medical Colleges. Based on the most recent analysis in 2015, the marked innovation of medical education, such as an integrated curriculum, active learning, and clinical clerkship, was recognized.</p>
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A 65-year-old man was admitted with subacute myocardial infarction. During medical treatment, the patient lost consciousness as a result of an atrioventricular block and underwent an operation for an emergency percutaneous coronary intervention in the right coronary artery. In a follow-up examination, transthoracic echocardiography and computed tomography showed a left ventricular pseudo-false aneurysm, and therefore another operation was carried out. The operative findings showed that the heart markedly adhered to the pericardium and the aneurysm at the apex. The patient then underwent a double-patch closure of the ruptured point using an equine pericardial patch and a Dacron patch. No perioperative complication was observed. Left ventricular pseudo-false aneurysm is a rare complication following myocardial infarction. Here, we report a successful case of a double-patch closure of a pseudo-false aneurysm.
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We report a case of minimally invasive cardiac surgery treated by small right intercostal thoracotomy for left atrial myxoma after substernal reconstruction of the esophagus using gastric interposition. This technique could not only alleviated risk at the second median sternotomy, but was also minimally invasive. A 63-year old man was admitted to our hospital for complaints of right upper limb asthenia and slight fever. Computed tomography showed cerebral infarction. Moreover, cardiac ultrasonography showed a giant myxoma in the left atrium. We thought that it was impossible to reperform median sternotomy, because there was high risk of injury to the reconstructed esophagus using a gastric duct behind the sternum. The patient underwent excision of the myxoma by the right intercostal thoracotomy approach, and did well. He was discharged from the hospital without any complications.
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A 67-year-old man was given a diagnosis of lung cancer and thoracic aortic aneurysm (TAA). We first performed thoracic endovascular repair (TEVAR), and then right lower lobectomy for lung cancer. TEVAR shortened the operation time and yielded less operative damage. Therefore, TEVAR can be an effective choice for simultaneous surgery of TAA and lung cancer.
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We report a rare case of vasculo-Behçet's disease complicated by an intracardiac thrombus. A 48-year-old woman with a history of Behçet's disease and deep vein thrombosis in a lower limb, and who had been treated with colchicine and warfarin, was given a diagnosis of an appendectal tumor by colonoscopy. Preoperative examinations, including chest computed tomography, showed a pedunculated mobile tumor from her inferior <i>vena cava</i> (IVC) to the right atrium (RA). Urgent surgery was performed to prevent pulmonary embolism. We exposed the RA through a median sternotomy under cardiopulmonary bypass and extirpated the tumor that appeared macroscopically to be an organized thrombus attached to the IVC wall. The pathological diagnosis was organized thrombus. A month later, she underwent ileocecal resection and was given a pathological diagnosis of mucinous cystadenoma. Her postoperative course was uneventful. Intracardiac thrombus complicated by vasculo-Behçet's disease is rare, and it is important in the differential diagnosis of intracardiac tumor.
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An 84-year-old man, who had been given a diagnosis of advanced aortoventricular block 2 years previously, underwent implantation of a pacemaker (PM) through the left subclavian vein. However, 7 months later a skin ulcer developed at the implantation site, but without any evidence of bacterial infection. Therefore, a PTFE-covered PM battery was reimplanted at the same site. Three months later, the skin ulcer recurred and he received a third implantation in the right side. However, another skin ulcer with infection developed in the right side. He was then transferred to our hospital for another PM reimplantation. We covered the battery and the entire lead with PTFE, then placed the PM lead directly into the cardiac muscle, and implanted the PM battery below the rectal muscle under general anesthesia. A patch test 4 months later revealed a positive reaction to nickel and silicon. Finally, we diagnosed pacemaker dermatitis. The patient has remained free of skin ulcers for over 1 year.
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A 34-year-old woman had received a diagnosis of X-linked hypophosphatemic osteomalacia when she was born. As an adult she complained of general fatigue, palpitations dyspnea exertional and leg edema. Transthoracic echocardiography showed aortic stenosis and regurgitation with severe aortic valve calcification. Chest computed tomography revealed her ascending aorta to be circumferentially calcified. Surgery was performed through a median sternotomy via cardiopulmonary bypass, with perfusion from the right subclavian artery and the right femoral artery and drainage from the superior and the inferior venae cavae. A left ventricular venting cannula was inserted from the right superior pulmonary vein. When her bladder temperature had dropped to 28°C by central cooling, we stopped the perfusion from the right femoral artery and performed aortotomy. We examined the lumen and clamped the aorta at the usual site, while flushing with blood by femoral perfusion. Aortic valve calcification was observed to extend from the sinus of valsalva to the outflow tract of the left ventricle on the non-coronary cusp side. He was necessary to repair the aortic annulus due to a defect resulting from careful removal of the calcified valve. We then performed aortic valve replacement using a 19-mm Carpentier-Edwards perimount Magna. Her postoperative course was uneventful without any sign of neurological complications, and she was discharged 13 days after surgery. On pathological examination, localized ossification with calcification was observed in her aortic valve which seemed to be characteristic of X-linked hypophosphatemic osteomalacia.
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We report two cases of coronary artery fistulas (CAF) in children with successful surgical repair. The first case was a 14-year-old boy with a continuous heart murmur. A fistula was diagnosed between the right coronary artery (RCA) and the right atrium by echocardiography. He was asymptomatic, but the pulmonary to systemic flow ratio was shown to be high by cardiac catheterization. He underwent surgical closure of the fistula and coronary artery bypass grafting to the RCA with the right interthoracic artery. The second case was a 5-year-old boy with a continuous heart murmur and cardiomegaly on the chest X-ray film. The CAF from the left coronary artery to the right atrium was revealed by echocardiography. The pulmonary to systemic flow ratio was shown to be high by cardiac catheterization. He was asymptomatic, but he also underwent surgical closure of CAF. Surgical repair was effective and safe in these cases. Echocardiography was very useful in the diagonosis of CAF. Surgical repair in the young is recommended because CAF is much more likely to cause congestive heart failure, angina, and infective endocarditis when growing.
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A 38-year-old man underwent surgery for impending rupture of an inflammatory celiac artery aneurysm with a maximum diameter of about 50 mm. First, an extra-anatomical bypass was performed from the iliac arteries to the celiac artery, superior mesenteric artery and bilateral renal artery using ringed ePTFE grafts. Second, the celiac artery aneurysm at the distal site was directly closed and then a stent graft was placed in the abdominal aorta to cover the orifice of the celiac artery. An endovascular stent graft treatment combined with extra-anatomical bypass is useful for the treatment of inflammatory aneurysm to avoid the various surgical complications in Behçet syndrome.
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A 46-year-old man was given a diagnosis of hypertension about 20 years previously. At age 41, aortitis syndrome was diagnosed, with descending thoracic aortic aneurysm and the coarctation of abdominal aorta by CT scan. He then underwent surgery to replace the descending thoracic aortic aneurysm and right axillo-bifemoral bypass. Recently, a thoraco-abdominal aortic aneurysm was pointed out at the distal site of the graft and, he was referred to our institute. We occluded the distal end of the aneurysm using an endoluminal occlusion stent graft. Today, in most cases of aortopathy associated with aortitis syndrome, surgical replacement of the aneurysms and extra-anatomical bypass is performed. An endovascular stent graft treatment combined with extra-anatomical bypass could be useful for various aortic disorders.
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A 20-year-old man suddenly complained of back pain and bilateral lower limb weakness. Computed tomography showed acute type B aortic dissection. The patent false lumen extended from distal arch to the left common iliac artery. The true lumen was severely compressed by the false lumen and both legs were ischemic. He underwent emergency fenestration of the abdominal aorta and stenting of the left iliac artery. Although the lower limbs ischemia was improved, he developed myonephropathic metabolic syndrome and received plasma exchange, continuous hemodialysis and endotoxin absorption therapy. Thirteen days after the operation, intestinal ischemia occurred and he underwent emergency bowel resection with creation of a stoma. Development of dissection to the superior mesenteric artery (SMA) and the malperfusion of SMA by severe compression of the true lumen were thought to cause intestinal ischemia.