Need for radiation safety education for interventional cardiology staff, especially nurses.

OBJECTIVE: Cardiac interventional radiology (IR) can cause radiation injury to the staff who administer it as well as to patients. Although education in the basic principles of radiation is required for nurses, their level of radiation safety knowledge is not known. The present study used a questionnaire protocol to assess the level of radiation safety knowledge among hospital nurses. METHODS AND RESULTS: A questionnaire to assess the level of training and current understanding of radiation safety was administered to 305 nurses in 2008 and again to 359 nurses in 2010. Our study indicates that nurses had insufficient knowledge about radiation safety, and that a high percentage of nurses were concerned about the health hazards of radiation. Moreover, more than 80% of the nurses expressed an interest in attending periodic radiation safety seminars. Annual radiation protection training for hospital staff (including nurses) is important. CONCLUSIONS: Our results suggest that nurses do not have sufficient knowledge of radiation safety and should receive appropriate radiation safety training. Many had a minimal understanding of radiation and thus had significant concerns about the safety of working with radiation. Periodic radiation safety education/training for nurses is essential.

Evaluation of spinal cord ischemia with a retrievable stent graft is useful for determining the type of repair for a case of patch aneurysm.

Patch aneurysms after thoracoabdominal aortic aneurysm repair are a serious late complication. We treated a patient with patch aneurysm (originating at the artery of Adamkiewicz) involving a portion of an implanted graft from a previous operation. First, thoracic endovascular aneurysm repair was planned. A retrievable stent graft was inserted, and motor-evoked potentials were monitored to evaluate spinal cord ischemia. Significant changes in the motor-evoked potentials were observed, and permanent stent graft placement was abandoned. Later, open surgery was performed. The patient showed no postoperative paraplegia and was discharged in good condition.

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.

[Leg amputation for severe lower limb ischemia caused by type A acute aortic dissection; report of a case].

A 41-year-old man underwent total arch replacement and aorto-bifemoral bypass owing to type A acute aortic dissection complicated by ischemia of both lower extremities. Just after the operation, he developed myonephropathic metabolic syndrome due to severe ischemia of the right leg, and hemodiafiltration was performed. However, the serum potassium was elevated to an uncontrollable level. Ligation of the right femoral artery and the right branch of the bypass graft was performed one hour after the transfer to intensive care unit (ICU), and the serum potassium dropped to a normal level. He underwent amputation of the right lower limb above the knee on the 13th postoperative day, and was discharged after long-term rehabilitation.

Surgical treatment for an asymptomatic and unruptured sinus of Valsalva aneurysm: report of a case.

A 70-year-old male underwent a transthoracic echocardiography as a screening test for hypertension and an unruptured aneurysm was detected in the right sinus of Valsalva. The right sinus of Valsalva aneurysm obstructed the right ventricle outflow tract but he did not have any symptoms. The sinus of Valsalva aneurysm was treated successfully by a patch closure with a bovine pericardial patch.

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.

[Thoraco-abdominal aortic replacement in chronic phase in a patient with temporary paraplegia after Stanford B acute dissection].

A 42-year-old man underwent was performed with thoraco-abdominal aneurysm replacement accompaniedy with reconstruction of abdominal branches and intercostal arteries. Eighteen months before, he had suffered from Stanford already been cured with paraplegia on being type B acute aortic dissection combined with paraplegia. When paraplegia had been occurred, cerebrospinal fluid drainage was had been performed promptly, and 4 days later, neurologic deficit was disappeared in 1 day. During the thoraco-abdominal aortic operation, cerebrospinal fluid drainage was performed done again. After the operation, paraplegia did was not occurred and he did not feel somewhat wrong with his legs. He was discharged from hospital on foot by himself. This case showed the efficacy of cerebral spinal fluid drainage for not only both with the prevention but also and treatment of paraplegia.

[The effects of Trans Pacific Partnership (TPP) for Japanese medical system].

The effects of Trans Pacific Partnership (TPP) for Japanese medical system were analyzed concretely. TPP has a great influence on the Japanese medical system, although, it was supposed that most of them would be capable to resolve except kaihoken: health insurance for all.

[Distal aortic repair after aortic arch replacement].

BACKGROUND: It is crucial to expose the proximal aorta in distal aortic repair, i.e., replacement of the descending thoracic aorta (DTA) or the thoracoabdominal aorta (TAA), after aortic arch replacement. With the elephant trunk (ET), it is usually easy to expose and clamp it. On the other hand, without the ET, it may be difficult or impossible to expose the proximal aorta and deep hypothermic circulatory arrest (DHCA) will be required. METHODS: Between April 1989 and March 2007, 17 patients underwent distal aortic repair after aortic arch replacement. Five patients underwent replacement of DTA and 12 of TAA. Five patients without the ET needed DHCA and open proximal anastomosis [OP (+) group], while in 12 patients, the ET or proximal aorta was successfully clamped [OP (-) group]. RESULTS: The mean extracorporeal circulation time in OP (+) group was significantly longer than that in OP (-) group (415 +/- 131 min v.s. 267 +/- 109 min, p < 0.05). There was no hospital death, cerebral infarction, fatal arrhythmia or low output syndrome in either group, and paraplegia in 2 patients and renal failure requiring hemodialysis in one were found only in OP (+) group. CONCLUSION: The ET procedure enables to avoid DHCA and may contribute to improving operative results in distal aortic repair after aortic arch replacement.

Modification of the descending thoracic aortic anastomotic site using biodegradable felt: study in a canine model with or without basic fibroblast growth factor.

OBJECTIVES: We investigated the outcomes of reinforcing anastomotic sites using (1) nonbiodegradable polytetrafluoroethylene (PTFE) felt, (2) biodegradable polyglycolic acid (PGA) felt, and (3) PGA felt with basic fibroblast growth factor (bFGF) in a canine descending thoracic aortic replacement model. METHODS: Thirty-seven beagles underwent descending thoracic aorta replacement using a prosthetic graft with one of the above-mentioned reinforcements or no reinforcement for controls. Histologic evaluations were carried out 1 month and 3 months after surgery. The biomechanical strength of the anastomosis was assessed along the longitudinal axis of the aortic segments using a tensile tester. Local compliance at the anastomotic site was also evaluated in the circumferential direction. RESULTS: The media was significantly thinner in the PTFE group than in the control group (65.8% +/- 5.1% vs 95.0% +/- 9.3% of normal thickness; P < .05). Relative to the control group, the adventitial layer was significantly thinner in the PTFE group (42.3% +/- 8.2% of control; P < .05) but significantly thicker in the PGA and the PGA + bFGF groups (117.2% +/- 11.3% and 134.1% +/- 14.2% of control, respectively; P < .05). There were more vessels in the adventitial layer in the PGA + bFGF group than in the control, PTFE, and PGA groups (29.2 +/- 2.1/mm(2) vs 13.8 +/- 0.8, 5.4 +/- 0.7, 17.0 +/- 1.3/mm(2), respectively; P < .01). There were no significant differences between the four groups in the failure force at anastomotic sites. Local compliance at the anastomotic site was higher in the PGA group than that in the PTFE group (11.6 +/- 1.6 10(-6) m(2)/N vs 5.6 +/- 1.9 10(-6) m(2)/N; P < .05). CONCLUSION: Reinforcement of the experimental aortic wall with PTFE felt resulted in thinning of the media and adventitia and fewer vessels at the anastomotic site. These histologic changes were not observed when biodegradable felt was used. The bFGF failed to augment the modification of the aortic wall with the exception of increased adventitial vessel number. Biomechanical strength of the anastomosis along the longitudinal axis was comparable in all four groups; however, local vascular compliance was better in the biodegradable PGA felt group.

The fate of bioprostheses in middle-aged patients: the Japanese experience.

BACKGROUND AND AIM OF THE STUDY: Although the trend of bioprosthesis use has been evaluated extensively, the durability of currently available bioprostheses has not been determined in middle-aged patients. The study aim was to determine the long-term fate of bioprostheses implanted in patients aged < 60 years. METHODS: Valve implantation data were collected from 43 centers in Japan. The data included patient age at implantation, type of valve, implant position, follow up period, and cause of reoperation including structural valve deterioration (SVD) and non-SVD. Between 1975 and 2005, a total of 697 bioprostheses was implanted in the mitral position, and 247 in the aortic position. The mean follow up period was 9.2 years. Rates of freedom from SVD and reoperation were determined using an actuarial method. RESULTS: The mean age at implantation was 45 +/- 10.9 years. The 15-year freedom from SVD was 39% for those with valves implanted in the aortic position, and 27% in the mitral position (p = 0.004). For the same period, the actuarial freedom from reoperation was 31% for valves in the aortic position, and 24% in the mitral position (p = 0.178). The difference in actuarial freedom from SVD was not significant between age groups in the mitral position. However, there were differences in actuarial freedom from SVD in the aortic position for patients aged < 10 years when compared to the other age groups (p < 0.001). New-generation valves showed better long-term durability than older valves (p = 0.05). CONCLUSION: The long-term freedom from SVD in middle-aged patients was unfavorable for bioprostheses implanted in the aortic and mitral positions. Middle-aged patients must be made aware that reoperation will be necessary; consequently, the choice of bioprosthesis should be dictated by patient-surgeon preference.

Japanese guidance for ventricular assist devices/total artificial hearts.

To facilitate research and development (R&D) and to expedite the review processes of medical devices, the Ministry of Health, Labor and Welfare (MHLW) and the Ministry of Economy, Trade and Industry (METI) founded a joint committee to establish guidance for newly emerging technology. From 2005 to 2007, two working groups held discussions on ventricular assist devices and total artificial hearts, including out-of-hospital programs, based on previous guidance documents and standards. Based on this discussion, the METI published the R&D Guidelines for innovative artificial hearts in 2007, and in 2008 the MHLW published a Notification by Director regarding the evaluation criteria for emerging technology.

[Surgeons' hope: expanding the professional role of co-medical staff and introducing the nurse practitioner/physician assistant and team approach to the healthcare system].

The healthcare system surrounding surgeons is collapsing due to Japan's policy of limiting health expenditure, market fundamentalism, shortage of healthcare providers, unfavorable working environment for surgeons, increasing risk of malpractice suits, and decreasing number of those who desire to pursue the surgery specialty. In the USA, nonphysician and mid-level clinicians such as nurse practitioners (NPs) and physician assistants (PAs) have been working since the 1960s, and the team approach to medicine which benefits patients is functioning well. One strategy to avoid the collapse of the Japanese surgical healthcare system is introducing the NP/PA system. The division of labor in medicine can provide high-quality, safe healthcare and increase the confidence of the public by contributing to: reduced postoperative complications; increased patient satisfaction; decreased length of postoperative hospital stay: and economic benefits. We have requested that the Ministry of Health, Labor and Welfare establish a Japanese NP/PA system to care for patients more efficiently perioperatively. The ministry has decided to launch a trial profession called "tokutei (specifically qualified) nurse" in February 2010. These nurses will be trained and educated at the Master's degree level and allowed to practice several predetermined skill sets under physician supervision. We hope that all healthcare providers will assist in transforming the tokutei nurse system into a Japanese NP/PA system.

[Use of a vacuum-assisted closure system for the treatment of mediastinitis after cardiac and aortic surgery].

The complications associated with postoperative mediastinitis represent a significant cause of morbidity and mortality within a subset of cardiac surgical patients. Reports on the most appropriate therapeutic intervention for its resolution vary. The vacuum-assisted wound closure (VAC) system is a new noninvasive treatment modality to enhance granulation in nonhealing and infected sternotomies. The system essentially provides negative pressure by controlled suction on the wound surface. We used the VAC system for the treatment of postoperative mediastinitis in 13 patients between 2003 and 2006. Twelve (92%) patients became free of mediastinitis after treatment with the VAC system, and 10 (77%) patients were eventually discharged. No adverse outcome of VAC treatment was encountered during the course of therapy. The VAC system is an efficacious treatment modality for postcardiotomy mediastinitis including deep sternal methicillin-resistant Staphylococcus aureus wound infection. Recurrent mediastinitis was not observed among the patients who underwent VAC treatment as definitive therapy and as a bridge to omental or muscle flap transfer.

[Comparison of therapeutic strategies for cardiovascular disease between Western countries and Japan].

A comparative review was performed to clarify the differences in therapeutic strategies and operative results in cardiovascular disease between Western countries and Japan, with the following results. (1) The operative results in the U.S.A. among patients with common cardiovascular diseases were almost the same as among those in Japan, except among those who underwent thoracic descending aortic and thoracoabdominal aortic repair. (2) The number of off-pump coronary artery bypass grafts performed comprises 20% to 30% of all coronary revascularization procedures in Western countries, while in Japan the number exceeds 60%. (3) Total endoscopic coronary artery bypass grafting and percutaneous aortic valve implantation can be performed safely but are currently restricted to only a few indications and are associated with several problems that require further improvement. However, these procedures clearly have the potential for extended indications and improved operative results. In these areas, Western countries are ahead of Japan. (4) Selective cerebral perfusion is a safer method of cerebral protection during aortic arch repair compared with retrograde cerebral perfusion and hypothermic circulatory arrest. Many Japanese cardiovascular surgeons have contributed greatly to advances in this method.

Safety and durability of the biodegradable felt in aortic surgery: a propensity score-matched study.

OBJECTIVES: Suture line disruption is a serious complication after aortic surgery. We previously reported in a canine model that basic fibroblast growth factor-incorporated biodegradable polyglycolic acid (PGA) felt prevented tissue derangement at the anastomotic site. This study sought to evaluate the safety and durability of this biodegradable felt. METHODS: Between January 2007 and December 2011, 67 patients who consented to undergo aortic surgery with the basic fibroblast growth factor-incorporated PGA felt were enrolled (Group P). As a control, we retrospectively reviewed the charts of 129 patients who underwent aortic surgery using a polytetrafluoroethylene felt during the same registration period (Group N). On the basis of 18 preoperative covariates, 60 well-matched patient pairs were identified using propensity matching, and their clinical indices were compared. RESULTS: Among the matched pairs, in-hospital mortality and postoperative complication rates did not statistically differ between the groups. During a median follow-up of 4.8 years, the rate of anastomotic aneurysm was 1.7% (1 patient) in both groups. The rates of overall survival and freedom from aortic events did not differ between the groups. In total, 65 anastomoses in Group P and 54 anastomoses in Group N were monitored via computed tomography, and the diameters of the juxta-anastomotic sites in Group N were more likely to be increased than those in Group P {dilatation ratio [(post-discharge diameter - predischarge diameter)/predischarge diameter × 100 (%)]: 4.3% ± 0.6% vs 2.5% ± 0.5%, P = 0.01}. CONCLUSIONS: The basic fibroblast growth factor-incorporated PGA felt was as safe and durable as conventional felt for reinforcement in aortic surgery. The attenuation of juxta-anastomotic aortic dilatation by PGA felt reinforcement may provide more beneficial effects on long-term outcomes.

Suppressive effect of pitavastatin on aortic arch dilatation in acute stanford type B aortic dissection: analysis of STANP trial.

OBJECTIVES: Medical therapy for patients with uncomplicated acute type B aortic dissection (ABAD) is essentially accepted for its excellent early outcome; however, long-term outcomes have not been satisfactory due to aorta-related complications. This trial was performed to investigate the efficacy of a statin as an additive that may enhance the effectiveness of conventional medical treatment in patients with ABAD. METHODS: This was a multi-center, prospective, and randomized comparative investigation of patients with uncomplicated ABAD. Fifty patients with ABAD compatible with inclusion criteria were randomly assigned to two groups and then received administration of pitavastatin (group P) or not (group C). We followed up the patients for 1 year from study onset. RESULTS: Two patients demised during the follow-up period (both were in group C). In addition, aorta-related interventions were performed in two patients (entry closure for aortic dissection by endovascular repair in one patient in each group). Aortic arch diameters at 1 year in group P tended to be smaller than in group C (P = 0.17), and the rate of change of the aortic arch diameters from onset to 1 year was significantly lower in group P (P = 0.046). Multivariate analysis identified patency of the false lumen was detected as a risk factor for aortic arch dilatation (P = 0.02), and pitavastatin intake was a negative risk factor (P = 0.03). CONCLUSIONS: Pitavastatin treatment, in addition to the standard antihypertensive therapy, may have a suppressive effect on aortic arch dilatation in patients with ABAD.

Isolation and characterization of vasohibin-2 as a homologue of VEGF-inducible endothelium-derived angiogenesis inhibitor vasohibin.

OBJECTIVE: We recently isolated vasohibin, a novel vascular endothelial growth factor (VEGF)-inducible endothelium-derived angiogenesis inhibitor. Our aim is to find DNA sequences homologous to vasohibin and determine their expression profile. METHODS AND RESULTS: By the search of DNA sequences in the database, we found one homologous gene and designated it vasohibin-2. Overall amino acid sequence homology between the prototype vasohibin (vasohibin-1) and vasohibin-2 was >50%. Vasohibin-2 exhibited antiangiogenic activity. Vasohibin-2 expression in cultured endothelial cells was low and not inducible by the stimulation that induced vasohibin-1. However, the immunohistochemical analysis revealed that vasohibin-1 and -2 were diffusely expressed in endothelial cells in embryonic organs during mid-gestation. After that time point, vasohibin-1 and -2 became faint, but persisted to a certain extent in arterial endothelial cells from late gestation to neonate. Expression of vasohibin-1 and -2 could be augmented in vivo by local transfection with the VEGF gene in the embryonic brain or by cutaneous wounding in adult mice. CONCLUSIONS: These results suggest that vasohibin-2, in combination with vasohibin-1, forms a novel family of angiogenesis inhibitors.