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We reported our long-term results of valve sparing aortic root replacement (VSRR) and aortic cusp repair for aortic regurgitation( AR) were satisfactory. Three hundred twenty-seven patients had VSRR, and 164 patients of them had aortic cusp repair for prolapse. At 10 years after the operation, the overall survival was 91.5%, the freedom from more than mild recurrent AR was 71.2%, and the freedom from aortic valve reoperation was 82.0%. As for the aortic cusp repair technique, there was no significant difference in the mid-term results of the recurrent AR and reoperation for the aortic valve between the central plication technique and the resuspension technique (two layers of continuous mattress sutures placed the entire length of the free margin of the aortic cusp). The resuspension technique might be useful for repairing the aortic cusp with prolapse. Furthermore, among the patients with acute aortic dissection, connective tissue disease, or aortitis, the long-term results of VSRR and aortic cusp repair were also satisfactory.

Malperfusion syndrome of the visceral branches associated with acute aortic dissection brings an extremely poor outcomes leading to perioperative and long-term mortality in both Stanford type A and type B acute aortic dissection. The conventional surgical strategy for these cases has been to prioritize aortic repair and to improve blood flow of true lumen in aorta and visceral branches. Today, various techniques for early reperfusion have been reported. For bowel ischemia, it is necessary to evaluate substantial ischemia of the intestinal tract and hypoperfusion of the superior mesenteric artery( SMA) using contrast-enhanced computed tomography( CT) and intraoperative transesophageal echocardiography in addition to clinical presentation. The most important factor of the surgical intervention is the improvement of true luminal blood flow by reconstruction of the central aorta. However, an intervention to SMA prior to central aortic repair might be an important process for patients with Stanford type A acute aortic dissection to avoid irreversible bowel necrosis. In type B aortic dissection, thoracic endovascular aortic repair (TEVAR) with or without provisional extension to induce complete attachment (PETTICOAT) technique and additional SMA intervention based on intraoperative contrast findings are necessary. Renal malperfusion is also a risk factor of postoperative accute kidney injury( AKI) and perioperative mortality. The revascularizations of renal arteries might improve outcomes when renal blood flow was not recovered with central aortic repair.

Surgical outcomes for acute type A aortic dissection (ATAAD) have been improving, but mortality rate remains about 10% in the last decade. Based on the current literatures including American Association for Thoracic Surgery (AATS) expert consensus, we presented the latest treatments and our surgical strategies for ATAAD. This section states about cannulation strategies for cardio-pulmonary bypass, aortic root managements, aggressive arch strategies, distal anastomosis strategies and the managements of malperfusion syndrome. We recommended the ascending aorta using the Seldinger technique as the cannulation site. As the aortic root management, valve resuspension is effective, but valve-sparing aortic root repair may be an option for young patients with annulo-aortic ectasia, intimal tear located in Valsalva sinus or Valsalva sinus rupture. The tear-oriented surgery is the standard for the range of the graft replacement, however, aggressive arch repair is also good indication for young patients. Distal anastomoses are felt sandwich technique for hemi-arch replacement or partial arch replacement and frozen elephant trunk is useful to total arch replacement. Early reperfusion strategies were important to the malperfusion syndrome of coronary arteries, supra-aortic vessels and superior mesenteric artery. To the dissected common carotid arteries (CCAs), early reperfusion and direct reconstruction of CCAs were effective.

We presented our experiences of reoperative aortic root replacement and technical details. Between April 2000 and February 2021, 80 patients underwent reoperative aortic root replacement (60 male, mean age 59.3±14.4 years). The previous procedures were ascending or arch replacement in 36, aortic valve replacement (AVR) in 32, and aortic root replacement in 12. Surgical indications for reoperation included infective endocarditis or graft infection (n=31), root dilation/dissection (n=26), pseudoaneurysm(n=13), aortic valve regurgitation( n=7), and structural valve dysfunction( n=3). Mean interval from 1st operation was 6.7±6.1 years. Reoperative procedures were composed of modified Bentall( n=27), reimplantation technique (n=25), root replacement with stentless valve (n=16), partial remodeling/patch plasty( n=5), Commando operation( n=5), and Ross operation( n=2). In-hospital mortality was 8.8%(7/80 patients). The causes of mortality were sepsis in 3, pneumonia in 2, bowel perforation in 1, and anastmotic rupture with mediastinitis in 1. Freedom from 3rd time aortic root related opera tion was 90.8±4.8% at 10 years. Actuarial survival after reoperation was 67.3±6.6% at 10 years. In conclusion, the clinical short-and long-term outcomes of reoperative aortic root replacement were reasonable even in patients with complicated aortic pathologies.

Objectives: Total arch replacement( TAR) is used to be a complicated and quite invasive aortic procedure. To perform TAR safely and effectively under all circumstances, we have constructed standardization of the procedures of TAR. The aim of this study is to analyze the impact of surgeons' experience on surgical outcome of TAR to evaluate our standardization., Methods: From January 2008 to December 2020, 346 consecutive patients (mean age 73.6±10.2) underwent elective TAR through a median sternotomy at our institute. TAR was performed by three types of surgeon classified by their experience( A:over 20 years, B:15~20 years, C:under 15 years). The surgical outcomes were examined. Our standard approach include( 1) meticulous selection of arterial cannulation site and type of arterial cannula;(2) antegrade selective cerebral perfusion;(3) maintenance of minimal tympanic temperature between 20 ℃ and 23 ℃;(4) early rewarming just after distal anastomosis;(5) maintaining fluid balance below 1,000 ml during cardiopulmonary bypass., Results: The operative cases were 227 in A, 86 in B and 33 in C. Surgeon A operated more complicated TAR with higher operative risk compared with B and C. The hospital mortality and major complication rate was not significant difference among surgeons( hospital mortality A:3.5%, B:2.3%, C:3.0%). Multivariate analysis showed the surgeons' experience was not associated with hospital mortality and major complications. Long-term outcomes were also compatible among three groups., Conclusions: Our standardization for TAR seemed to be an useful approach to eliminate the impact of surgeon experience on surgical outcomes if the type of surgeon was appropriately selected according to the level of operative difficulty.

A hybrid operating room(Hybrid OR), where operative equipment and flat panel angiography are both available, is becoming common for complex cerebrovascular surgery. However, the current Hybrid OR remains suboptimal as it is not cost-effective and contains uncomfortable operating beds, and a single-plane flat panel. Therefore, we introduced a novel Hybrid OR system, which has a biplane flat panel detector and three mutually exchangeable tailor-made operating beds. In this article, we report our preliminary experience of this novel Hybrid OR, focusing on improved cost-effectiveness by the availability of diagnostic angiography and standard endovascular surgery, optimal selection of three different types of operating beds, and procedural workflow in individual hybrid cerebrovascular surgery.

Although short and long-term outcomes of aortic surgeries have been improving over the past decade, the procedure is likely to be asscociated with life-threatening complications such as neurological deficits caused by suboptimal brain protection or heavily diseased aorta. Contemporary strategies for brain protection are deep hypothermic arrest with or without retrograde cerebral perfusion retrograde cerebral perfusion or selective antegrade cerebral perfusion. At the moment, majority of evidences failed to show the superiority of selective antegrade cerebral perfusion to retrograde one. Shaggy aorta( atherothrombotic aorta) was defined as very extensive atheromatous disease with diffuse ulcers associated with soft, loosely held debris and a paucity of actual thrombus and is the prototypical potential embolic source for neurological deficits. Non-physiological flow during cardiopulmonary bypass causes the detachment of atheroma and consequently the debris was washed away into the carotid arteries. Therefore, meticulous selection of cannulation site and type of cannula (a dispersion cannula) and complete exclusion of the diseased aorta contributed to avoiding permanent neurological deficits even when atherothrombotic aorta was present. Shaggy aorta combined with leukoaraiosis, extracranial carotid artery stenosis, and prolonged cardiopulmonary bypass time exponentially increased postoperative transient neurological deficits in patients undergoing total aortic arch replacement, and may therefore deserve special attention.

Within 8-year period between 2009 and 2016, we treated 215 patient with a strategy of primary thoracic endovascular aortic repair( TEVAR). In-hospital mortality was 4.4%( 8 cases). Thirty-two emergency cases was included and we treated 23 cases of zone 0 debranching TEVAR with chimney techinique in this period. In recent 2-year period between 2015 and 2016, we treated 44 cases of TEVAR without type I a endoleaks with 0% mortality(most of the them was zone 2~3 TEVAR in this period) on the one hand, and the number of open surgery for thoracic aorta was 80 on the other. TEVAR was also indicated for emergency and high risk cases even if their anatomical conditions were outside of instruction for use, and utilized for bridging or staged therapy for open surgery in our series. Standardization and refinement of endovascular procedures is considered to be important to improvement outcomes, and hybrid therapy or back up of open surgery should be collaborated with TEVAR for thoracic aortic aneurysm treatment.

Seroepidemiological studies on pertussis, diphtheria and tetanus were performed on 1,540 nursing students enrolled in S-university between 1994 and 2011. Antibody titers against pertussis toxin (PT) and filamentous hemagglutinin (FHA), diphtheria antitoxin titer, and tetanus antitoxin titer were measured using sera taken during enrollment. The antibody-seropositive rates and geometric mean titers (GMTs) were calculated by according to birth year (1975-1993). The pertussis anti-PT and anti-FHA antibody-seropositive rates (seropositive levels were both defined as ≥10 EU/mL) were 12%-53% and 47%-84%, respectively. The anti-PT antibody-seropositive rate was lower than the anti-FHA rate. The anti-PT antibody GMTs were 2.0-11 EU/mL, whereas the anti-FHA antibody GMTs were 10 EU/mL or more (8.8-31 EU/mL) in almost every group. The diphtheria antitoxin-seropositive rate (≥0.1 IU/mL) was 49%-79%, and the GMT was nearly 0.1 IU/mL. The tetanus antitoxin-seropositive rate (≥0.01 IU/mL) was 91%-100%, and the GMT was 0.3 IU/mL or more for all the groups. While the nursing students' diphtheria and tetanus antitoxin levels were sufficient to prevent both diseases, the anti-PT antibody-seropositive rate and the GMT were both lower than the level required to prevent pertussis, suggesting that many of the nursing students were pertussis-susceptible. These findings suggest a need for pertussis vaccination in young adults or early adolescents.

Objective: We report our current surgical management and early and late outcomes of total arch replacement., Method: From October 1999 to December 2012, 372 consecutive patients (mean age 71.8±12.0) underwent total arch replacement through a median sternotomy at our institute. Mean Japan score (predicted 30 day mortality) was 8.0±9.2( median 4.4). Our current surgical approach included the following:(1) meticulous selection of arterial cannulation site and type of arterial cannula;(2) circulatory arrest at tympanic temperature (below 23 °C) and rectal temperature (below 30 °C);(3) antegrade selective cerebral perfusion and cerebral monitoring of regional cerebral saturation;(4) early rewarming just after distal anastomosis;(5)maintaining fluid balance below 1,000 ml during cardiopulmonary bypass., Results: Overall 30 day and in-hospital mortality was 1.6%( 6/372) and 3.8%( 14/372), and was 1.0%(3/308)and 2.6% (8/308) in elective cases. Permanent neurologic deficit occurred in 2.2%(8/372) of patients. The mean follow up period were46±39months(range2~165 months). Survival at 5 and 10 years after surgery was 75.8±2.8% and 66.0±3.8%, respectively. During follow up period, there was only one total arch replacement related problem (proximal anastomosis aneurysm). Freedom from additional aortic surgery and aortic related event at 5 and 10 years was 90.8 ±2.2% and 86.1±3.4%,respectively., Conclusion: Our current approach for total aortic arch replacement was associated with low hospital mortality and morbidities and with favorable long-term outcome.

Background: Recently, the fraction of exhaled nitric oxide (FENO), which can be measured easily and noninvasively even in children, has attracted attention as a method of evaluating airway inflammation. The aim of this study was to investigate the relationship between compliance with inhaled corticosteroids (ICS) before a summer camp for asthmatic children and the changes in the FENO during camp., Methods: Fifty asthmatic children (26 boys and 24 girls) aged 6-12 years old were recruited from the Fukuoka National Hospital Summer Camp between 2008 and 2010. We measured their FENO on the first and last day of camp. The children were taught appropriate inhalation methods by pediatric pulmonologists and nurses and performed ICS under their supervision every day during the camp. Before the camp, we asked the participants to complete a questionnaire regarding the use of ICS. The participants were classified into four groups according to their adherence to this therapy. The changes in FENO were then examined and compared among the groups., Results: The FENO measured on the last day of camp was significantly lower than that measured on the first day of camp among children who tended to forget to perform ICS. However, no significant difference in the FENO measurements were observed during the camp, when the children were performing ICS every day., Conclusion: The FENO decreased significantly after only four days of camp in the poor compliance group. Therefore, teaching children the appropriate method for inhaling ICS is important, especially for children who tend to forget to perform ICS.

Background: The purpose of this study is to compare mitral valve replacement (MVR) to anuloplasty (MAP) in patients with severe functional mitral regurgitation (FMR)., Methods: Data of 43 patients with significant chronic FMR who underwent mitral valve operations from November 1999 through May 2011 were retrospectively analyzed. This reference group included patients who underwent MVR (n = 18) and MAP (undersized restrictive annuloplasty, n = 25). The mitral valve is replaced sparing the continuity between mitral valve and subvalvular apparatus. All patients had severe FMR, and 71.4% had New York Heart Association (NYHA) III or IV symptoms of heart failure, and 20% had preoperative intraaortic balloon pumping (IABP) insertion. The MVR group had significantly higher risk patients with complex jet and advanced coaptation depth (13.3 +/- 2.1 versus 11.1 +/- 2.3 mm, p = 0.04)., Results: Hospital mortality was 9.3%. No statistical difference was found between the 2 groups in term of intraoperative data. Kaplan-Meier survival estimates at 1, 5 years was 82.6, 72.3% in MVR group, and 77.8, 69.7% in MAP group (p = 0.98). Freedom from Cardiac-related event at 5 years was 62.7% for MVR compared to 56.8 % for MAP (p = 0.75). At the last follow-up, recurrence of MR II or greater was present in 4 (14.8%) patients in the MAP group and only one patient required re-operation because of worsening heart failure. In multivariable analysis, independent predictor of increased cardiac-related event was associated with residual pulmonary hypertension (HR, 3.0: p = 0.021)., Conclusions: In high-risk patients with severe FMR. MVR seems to be a reasonable option.

It introduced the case definition by the Brighton classification applied internationally and widely for the anaphylaxis following immunization.

Background: Though the epidemiological relationship between obesity and asthma has been widely investigated, the mechanism is less known. Several studies have examined that weight loss improved lung function in adults. However, it has not been systematically studied in children. We investigated the effect of weight reduction on respiratory function in obese children with asthma., Methods: We selected 10 obese children aged 7-13 years with physician diagnosed asthma who was subjected the weight reduction program in Fukuoka National Hospital in 2003-2007. Obesity was defined by BMI >90 percentile of the same age population. Before and after the program, they performed the spirometry. And they were measured the height, the weight, the %Fat, and the Fat volume. Logistic linear analysis was conducted to determine the correlation between relative change in each obesity markers and relative change in each respiratory parameter., Results: Reduction of BMI, %Fat, and Fat volume correlated with relative changes in %FVC and %FEV1. Reduction of %Fat and Fat volume also correlated with relative changes in %PEF and %V50., Conclusion: Reduction of BMI, %Fat, and Fat volume can improve respiratory function in obese children with asthma. Obesity may be contribute to aggravate the symptoms of asthma.

Infective endocarditis is a life-threatening disease that should be diagnosed based on Duke's criteria as early as possible. A positive blood culture and echocardiographic findings, particularly those of a transesophageal echocardiogram, play a pivotal role in the process of confirming a diagnosis. Medical treatment using appropriate antibiotics against the identified microorganism is of primary importance, although infective endocarditis is often accompanied by intracardiac or extracardiac complications and must be converted to surgery. The timing of surgery for patients with brain complications is crucial but still controversial because the usage of heparin for cardiopulmonary bypass (CPB) may cause the complications to deteriorate. We demonstrated that a novel CPB strategy with nafamostat mesilate as an anticoagulant may be potentially safe and useful in preventing deterioration of recent intracranial hemorrhage. Destructive aortic valve endocarditis causes the development of left ventricular-aortic discontinuity. In the past 8 years, 9 patients with left ventricular-aortic discontinuity underwent aortic root replacement in our institution. Radical debridement of the aortic root abscess was performed in all cases, followed by aortic root replacement with a pulmonary autograft (Ross procedure) or a stentless aortic root xenograft. No mortality was observed during hospitalization and follow-up. Freedom from major adverse cardiac events was noted in 67% of the patients at 5 years.

Under an environment that a vaccination rate is low and an infectious disease is prevalent, it is thought that most vaccinee got additional immunity by natural infection. On the other hand, in the area where the incidence of disease has been reduced by high rate vaccination, it is also decreased the chance of additional immunity by natural infection. Therefore susceptible individuals are increased because of the waning immunity. In the community where a vaccination rate is high, it may be necessary to consider the booster vaccination for adolescent and adult even if one completed the primary vaccinations. It may also be important to explore the timing of booster dose. In this paper, we attempt to give a comprehensive explanation of mathematical model for predicting the antibody duration, and we introduce the role of mathematical model on a consideration to the need and timing of booster doses after the primary series.

Measles and rubella combined (MR) vaccine and two-dose-vaccination have been used in Japan since 2006. only children undergoing monovalent measles and rubella vaccination undergo a second vaccination. We intend to administer MR vaccine twice to Japanese children from 2011, so studied the safety and efficacy of two-dose MR vaccination. Subjects were 75 pre school children undergoing MR vaccine manufactured by Biken at one year old in a clinical trial. Children were observed for adverse events for 28 days after the second MR vaccination. Efficacy was determined by measuring antibodies for measles and rubella before and after (six to eight weeks later) the second vaccination. Results showed that fever frequency decreased significantly from 27.3% to 14.9% (p < 0.05), and eruption decreased from 12.2% to 6.8% from the first to the second vaccination, whereas, the frequency of redness and swelling at the inoculation site increased from 7.3% to 10.8% and 2.9% to 8.1%. Differences are not statistically significant. Measles antibody titer determined by NT assay and rubella antibody titer measured by HI assay increased significantly from prevaccination to postvaccination (p < 0.0001). Measles antibodies measured by NT and EIA assays and rubella antibody measured by HI assay turned positive in all subjects after the second MR vaccination. In conclusion, two-dose MR vaccination should be safe and effective in eliminating measles and rubella in Japan.

Objective: To study the effect of treatment of latent tuberculosis infection (LTBI) on QuantiFERON TB-2G (QFT-2G) test results., Subjects and Methods: QFT-2G was used for a contact investigation in a junior high school and those positive or doubtful positive (TB Antigen-Nil response > or = 0.1 and < 0.35 IU/ml) were indicated for treatment of LTBI with INH. All subjects who completed treatment of LTBI were re-tested with QFT-2G approximately 1 month after completion of treatment and a subset were again re-tested 8 to 11 months after the completion of treatment. The levels of IFN-gamma response in each QFT-2G test were compared., Results: Initially, 43 subjects (28 QFT-2G positive and 15 doubtful positive) were indicated treatment of LTBI, and 41 (95%) completed 6-months treatment. These 41 subjects were re-tested with QFT-2G approximately 1 month after the completion of treatment. Among 28 pre-treatment positives, 19 remained positive, 6 became doubtful positive, and 3 reverted to negative. Among 13 pre-treatment doubtful positives, 1 converted to positive, 5 remained doubtful positive, and 7 reverted to negative. The QFT-2G responses after the completion of treatment significantly declined compared with the pre-treatment level (geometric means; before treatment ESAT-6: 0.30 IU/ml, CFP-10: 0.09 IU/ml, after treatment ESAT-6:0.18 IU/ml, CFP-10: 0.05 IU/ml, dependent t-test; ESAT-6: p = 0.020, CFP-10: p = 0.005). At 8 to 11 months after the completion of treatment, 30 randomly selected subjects received the third QFT-2G test. Among 19 positives at the completion of treatment, 14 remained positive, 4 become doubtful positive, and 1 reverted to negative. Among 8 doubtful positives at completion of treatment, 4 converted to positive, 3 remained doubtful positive, and 1 reverted to negative. A further decline of QFT-2G responses was not observed. Three subjects negative at the completion of treatment were re-tested and remained negative at the third test., Conclusion: QFT-2G responses significantly declined after the treatment of LTBI, despite the rate of reversion in QFT-2G being low. This low reversion rate suggests QFT-2G would not be useful as a marker to evaluate the success of treatment for LTBI. However, the finding that QFT-2G responses significantly decline after the treatment of LTBI suggests the possibility that this decline could be used as a marker of the susceptibility of the infective M. tuberculosis strain to the prophylactic drug used. The outbreak investigation has been carried out for over two years, and none of 229 students who were TST positive, but QFT-2G negative and because of this result not indicated treatment of LTBI, have developed TB, suggesting that QFT-2G reflects TB infection more accurately than the TST, even in school children.

Objective: This study evaluated the efficacy and safety of Budesonide Inhalation Suspension (BIS) nebulazation by mesh nebulizer in children ages 6 months to 4 years with moderate to severe persistent asthma., Method: This 12-week, randomized, open study involved 30 asthmatic children. They were randomized 3 different nebulizer groups, Pari TurboBoy +LC Plus nebulizer, Pari eMotion and Omron MicroAir NE-22U. BIS administered 0.25 mg once daily (qd). Efficacy was assessed by daily card. Safety was assessed by adverse event, plasma cortisol and growth., Result: Baseline concentrations of plasma cortisol were significantly high in the group of Omron MicroAir NE-22U compared to other group. Plasma cortisol were decreased significantly at 4 weeks in Omron MicroAir NE-22U compared with baseline, but those in no subjects decreased under normal range. Asthma symptoms were improved significantly from baseline to 12-week., Conclusion: This study demonstrate that usage of mesh nebulizer in BIS 0.25 mg qd is effective and safe in young asthmatic children.

We determined antimicrobial susceptibilities and analyzed molecular epidemiology of 26 strains of Bordetella pertussis clinically isolated and then performed pulsed-field gel electrophoresis (PFGE) in Japan (Japanese Pertussis Surveillance Group Participants), from 2001 to 2002. The MICs of erythromycin, clindamycin, tetracyclines, fluoroquinorones, trimethoprim-sulfamethoxazole and rifampicin of all isolates against these showed 1 microgram/ml or less. Sparfloxacin is the most potent agent, of which the MICs showed 0.008-0.016 microgram/ml. Results of DNA fingerprinting by pulsed-field gel electrophoresis (PFGE) differentiated three types (Type I; 11 strains (42%), type II; 14 strains (54%) and type III; 1 strains (4%)). However, no relation between regions and identical PFGE patterns was found in this study. Further, surveillance of the antimicrobial susceptibilities and molecular epidemiology of B. pertussis will be required.