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Purpose Hybrid aortic arch repair (HAR) has been implemented for extended aortic arch and descending thoracic aortic disease since 2012 in our institution. This study aimed to estimate the early and mid-term efficacy and safety of HAR. Materials and Methods From 2007 to 2019, 56 patients underwent HAR for extended aortic arch disease, and 75 patients underwent total arch replacement (TAR) for arch-limited disease. HAR comprises 3 procedures: replacement of the aorta, reconstruction of all arch vessels, and thoracic endovascular aortic repair (TEVAR) from zone 0 to the descending aorta after cardiopulmonary bypass is off in 1 stage. The type II-1 HAR procedure, in which the ascending aorta and aortic arch distal to the brachiocephalic artery are replaced, was the most frequently selected procedure (40/56 patients). The outcomes of the type II-1 HAR procedure were compared with those of TAR using the Cox regression analysis. Results The median follow-up period was 36 months. In HAR, the operative mortality, in-hospital mortality, and postoperative permanent neurological deficits were not observed. The paraplegia rate was 1.8%. TEVAR-related complications occurred in 3 patients. Among the patients with non-ruptured atherosclerotic aortic arch aneurysm (31 type II-1 HAR patients and 36 TAR patients, the postoperative respiratory support time in those who underwent type II-1 HAR was quicker than in those who underwent TAR (pConclusions HAR, especially the type II-1 procedure, can treat extended aortic arch disease with acceptable survival outcomes. The development of TEVAR technology will further improve the outcomes of HAR in the future.

Purpose: The principal of this analysis was to understand global feature of the number and type of grafts and number of diseased vessels of those undergoing coronary artery bypass grafting (CABG) and their short-term clinical results. Methods and Results: This report presents annual report on the collective data of CABG in the year 2018 (1 January–31 December). Data were collected based on the series of questionnaire which has been performed by The Japanese Association for Coronary Artery Surgery (JACAS), capturing the corresponding data from the Japan Adult Cardiovascular Surgery Database (JCVSD). We also analyzed descriptive clinical results of those undergoing surgeries for acute myocardial infarction and ischemic mitral regurgitation. Conclusion: This is the first article summarizing the results from annually performed questionnaires by JACAS based on JCVSD, on the trend of CABG procedures and clinical results in Japan as a scientific manuscript.

Extracorporeal membrane oxygenation (ECMO) plays an important role in the coronavirus disease 2019 (COVID-19) pandemic. Management of thrombi in ECMO is generally an important issue; especially in ECMO for COVID-19 patients who are prone to thrombus formation, the thrombus formation in oxygenators is an unresolved issue, and it is very difficult to deal with. To prevent thromboembolic complications, it is necessary to develop a method for early thrombus detection. We developed a novel method for detailed real-time observation of thrombi formed in oxygenators using indocyanine green (ICG) fluorescence imaging. The purpose of this study was to verify the efficacy of this novel method through animal experiments. The experiments were performed three times using three pigs equipped with veno-arterial ECMO comprising a centrifugal pump (CAPIOX SL) and an oxygenator (QUADROX). To create thrombogenic conditions, the pump flow rate was set at 1 L/min without anticoagulation. The diluted ICG (0.025 mg/mL) was intravenously administered at a dose of 10 mL once an hour. A single dose of ICG was 0.25mg. The oxygenator was observed with both an optical detector (PDE-neo) and the naked eye every hour after measurement initiation for a total of 8 hours. With this dose of ICG, we could observe it by fluorescence imaging for about 15 minutes. Under ICG imaging, the inside of the oxygenator was observed as a white area. A black dot suspected to be the thrombus appeared 6-8 hours after measurement initiation. The thrombus and the black dot on ICG imaging were finely matched in terms of morphology. Thus, we succeeded in real-time thrombus detection in an oxygenator using ICG imaging. The combined use of ICG imaging and conventional routine screening tests could compensate for each other's weaknesses and significantly improve the safety of ECMO.

Fractured tracheostomy tube is a rare, late complication. It typically occurs at the junction of metallic tube. We report an atypical case with laceration of the main trunk of a silastic tube after short period of use (10 days).

The aims of the present study were to establish a population pharmacokinetic (PPK) model of cefazolin for adult patients undergoing cardiac surgery with cardiopulmonary bypass (CPB) and to assess the probability of target attainment (PTA) for the prophylaxis of surgical site infection (SSI) using cefazolin. Adult patients who underwent cardiac surgery with CPB were enrolled in the prospective study. Blood samples for plasma cefazolin assay were collected, and total and unbound drug concentrations were measured and analysed using the nonlinear mixed-effects modelling (NONMEM) software considering saturable plasma protein binding. Using the PPK model, plasma unbound cefazolin concentration-time courses with current prophylaxis protocols were simulated, and the PTA for common SSI pathogens was estimated. A total of 199 blood samples were obtained from 27 patients. A one-compartment model with first-order elimination plus an on/off CPB compartment best described the data. The population mean for systemic drug clearance (CL) was reduced and that for the volume of distribution (V) was increased during CPB compared with the pre-CPB values. CPB-induced hypoalbuminemia was associated with reduced maximum protein binding (Bmax). The simulation studies suggested that the current dosing protocols are insufficient for attaining PTA > 0.9 throughout surgery against pathogens with minimum inhibitory concentrations (MICs) >8 mg/L. A new dosing protocol that achieves a PTA > 0.9 for pathogens with a MIC of 16 mg/L was proposed. PPK modelling with simulation may be valuable for devising a cefazolin prophylaxis protocol for patients undergoing cardiac surgery with CPB.

Takayasu arteritis (TA) occasionally involves the coronary ostium leading to myocardial ischemia. Although surgical coronary ostial angioplasty is desirable for ostial stenosis, the patch materials and long-term results are controversial. We used femoral artery (FA) as a patch material for coronary ostial angioplasty in 3 TA patients. Coronary ostial enlargement with a longitudinal incision followed by rectangular FA patch augmentation was performed to extend the narrowing coronary ostium. In all patients, coronary ostial stenosis was successfully repaired. Ostial angioplasty using an FA patch would be a reasonable surgical strategy to treat coronary ostial stenosis in TA.

Purpose We developed a heart positioner, the Tentacles NEO, specifically designed for minimally invasive coronary artery bypass grafting (MICS-CABG). Description The device has 3 flexible suction tubes, with a suction cup at the tip of each tube. The suction tubes can be detached from the device body, allowing them to be manipulated in any direction through a small incision around the small thoracotomy. When the device displaces the heart, the suction cup moves behind the chest wall and does not crowd the operative field. Evaluation Although the sideways suction force of the new device was as strong as that of the original device, Tentacles, the longitudinal and perpendicular force exerted was approximately 80% of the original device. Nevertheless, the new device could safely and favorably displace the heart in a pig model and even during off-pump CABG via sternotomy. During MICS-CABG, the device was able to displace the heart without crowding the operative field. Conclusions The new heart positioner, Tentacles NEO, is a useful and practical heart positioner suitable for MICS-CABG.

Purpose To stabilize the sternum after median sternotomy, unsintered hydroxyapatite poly-L-lactide (u-HA/PLLA) sternal pins are frequently used in Japan. However, sternal pins are ineffective in the fragile bone marrow. Thus, a corrugated sheet made of u-HA/PLLA was developed as a new sternal fixation device. Methods To examine the effects of the device, we measured the shear force using a sternal model and cadaver. The shear force of the corrugated sheet, sternal pin, and simple wire was compared. The device size was determined after reviewing the sternal computed tomography (CT) of 128 patients. Results The shear force of the model with the corrugated sheet (286 [256-295] N) was higher than that with sternal pins (135 [134-139] N, p = 0.03) and simple wire (94 [90-104] N, p = 0.03) at 2-mm displacement. In the cadaver test, the shear force of the sternal halves with the device was about two times higher than that without the device. Retrospective CT showed that 18-mm wide device applies to 99% male and 87% female patients at the fourth intercostal level. Conclusion The corrugated sheet might provide a stronger fixation effect in the fragile bone marrow. The device width was modified to 18 mm to be applicable for most Japanese patients.

Background: Thrombosis is a characteristic complication in coronavirus disease 2019 (COVID-19). Since coagulopathy has been observed over the entire clinical course, thrombosis might be a clue to understanding the specific pathology in COVID-19. Currently, there is limited epidemiological data of COVID-19-associated thrombosis in the Japanese population and none regarding variant strains of SARS-CoV-2. Here, we elucidate the risk factors and the pattern of thrombosis in COVID-19 patients.Methods: The patients consecutively admitted to Tokyo Medical and Dental University Hospital with COVID-19 were retrospectively analyzed. SARS-CoV-2 variants of concern/interest (VOC/VOI) carrying the spike protein mutants E484K, N501Y, or L452R were identified by PCR-based analysis. All thrombotic events were diagnosed by clinical symptoms, ultrasonography, and/or radiological tests.Results: Among the 516 patients, 32 patients experienced 42 thromboembolic events. Advanced age, severe respiratory conditions, and several abnormal laboratory markers were associated with the development of thrombosis. While thrombotic events occurred in 13% of the patients with a severe respiratory condition, those events still occurred in 2.5% of the patients who did not require oxygen therapy. Elevated D-dimer and ferritin levels on admission were independent risk factors of thrombosis (adjusted odds ratio 9.39 and 3.11, 95% confidence interval 2.08–42.3, and 1.06–9.17, respectively). Of the thrombotic events, 22 were venous, whereas 20 were arterial. While patients with thrombosis received anticoagulation and antiinflammatory therapies with a higher proportion, the mortality rate, organ dysfunctions, and bleeding complications in these patients were higher than those without thrombosis. The incidence of thrombosis in COVID-19 became less frequent over time, such as during the replacement of the earlier strains of SARS-CoV-2 by VOC/VOI and during increased use of anticoagulatory therapeutics.Conclusion: This study elucidated that elevated D-dimer and ferritin levels are useful biomarkers of thrombosis in COVID-19 patients. The comparable incidence of arterial thrombosis with venous thrombosis and the development of thrombosis in less severe patients required further considerations for the management of Japanese patients with COVID-19. Further studies would be required to identify high-risk populations and establish appropriate interventions for thrombotic complications in COVID-19.

Objective Mitral subvalvular procedures in addition to restrictive annuloplasty are promising for ischemic mitral regurgitation (IMR). However, the prevalence and efficacy of specific subvalvular repair in severe IMR have not been elucidated. This is the first nationwide survey regarding surgeons' attitudes toward IMR in Japan. Methods A questionnaire was sent to 543 institutions. From 2015 to 2019, numbers of elective first-time mitral valve replacement (MVR) with/without complete chordal preservation (CCP)/papillary muscle approximation (PMA) and mitral valvuloplasty (MVP) with/without papillary muscle relocation (PMR)/PMA in patients with severe IMR were collected. Concomitant procedures for coronary artery, tricuspid valve, and arrhythmia could be included but left ventricular reconstruction was excluded. Results Completed questionnaires were received from 286 institutions (52.7%). The majority (90%) had less than 20 cases within 5 years. The number of MVP (1413, 61.5%) surpassed MVR (886, 38.5%). CCP was performed in half of MVR (50.0%), while PMA was included in only 1.9% of MVR. PMA and PMR were also performed infrequently, in only 7.7% and 10.9% of MVP, respectively. Conclusion Japanese surgeons aggressively perform MVP for severe IMR. Subvalvular repair was also aggressively performed in addition to MVR, but not to MVP. A multicenter registry study is in progress.

Proper positioning of the heart through a small left thoracotomy is the main challenge during off-pump minimally invasive cardiac coronary artery bypass grafting. Here we report a novel technique for target vessel exposure using the Tentacles NEO (Sumitomo Bakelite, Co Ltd, Tokyo, Japan) multisuction heart positioner, a device with 3 independent small suction cups that can be applied to various surfaces of the heart and pulled toward any direction using attached traction cords. The armless design of the device enables the use of flexible exposure techniques and contributes to the safety and feasibility of minimally invasive coronary artery bypass grafting.

Pediatric thoracic aortic aneurysms are very rare, and almost all patients with such aneurysms have inflammatory or connective tissue diseases. This report describes a case involving 10-year-old girl who had an aortic arch and descending thoracic aortic aneurysm. Preoperative fluorine-18-fluorodeoxyglucose positron emission tomography combined with computed tomography showed an inflammatory lesion corresponding to the aneurysm's location. The ascending aorta, aortic arch, and descending thoracic aorta were replaced through median sternotomy and left thoracotomy with safe systemic and brain perfusion to avoid placing the anastomoses within the inflammatory lesion. The patient was discharged without complications, and an SMAD3 mutation was detected by postoperative mutational screening.

Hemocompatibility-related adverse events (HRAEs) are substantial issues in patients with left ventricular assist devices (LVADs). Atrial fibrillation (AF) is associated with worse prognosis in patients with heart failure (HF), but its effect on HRAEs following LVAD implantation remain uncertain.Methods and Results:Data from the Japanese Mechanically Assisted Circulatory Support registry of consecutive patients who received HeartMate II LVADs and were followed for 1 year were retrospectively reviewed. Among 190 patients, 23 had AF and 167 had sinus rhythm. The AF group had comparable baseline characteristics with the non-AF group except for their higher age (53 vs. 42 years, P0.001). Following LVAD implantation, most cases of AF (73%) persisted. Antiplatelet therapy, anticoagulation therapy, and LVAD speed following LVAD implantation were comparable between groups (P0.05 for all). The 1-year survival free from HRAEs was comparable between groups (83% vs. 76%, P=0.52). Event rates of the breakdown of HRAEs were comparable between groups except for a relatively higher rate of surgically managed pump thrombosis in the AF group (0.16 vs. 0.04, incidence rate ratio 3.75, 95% confidence interval 0.87-16.1, P=0.075). These trends still remained with propensity score-matched comparison.Existence of AF had no effect on the development of HRAEs following LVAD implantation. The need to aggressively treat AF before or after LVAD implantation needs further investigation.

Veno-venous extracorporeal membrane oxygenation (VV ECMO) is an effective and proven adjunct support for various severe respiratory failures requiring invasive mechanical ventilation and cardiovascular support. In response to the rapidly increasing number of COVID-19 patients in Japan, we launched an ECMO support team comprised of multidisciplinary experts including physicians, nurses, perfusionists, and bioethicists in preparation for the threat of a pandemic. From April 2 to July 15, 2020, Tokyo Medical and Dental University hospital treated 104 PCR confirmed COVID-19 patients. Among those, 34 patients were admitted to intensive care unit (ICU) and 5 patients required VV ECMO. All management related to ECMO was decided by the ECMO support team in addition to participation of the ECMO support team in daily multidisciplinary rounds in the ICU. Median age was 54 years old. Duration from onset to mechanical ventilation (MV) and MV to ECMO were 8 and 7 days, respectively. Four patients (80%) were successfully weaned off from ECMO. One patient died after 81 days of ECMO run. Four patients were discharged and recovered to their prehospital quality of life without major disability. We achieved a high survival rate using ECMO in our low volume ECMO institution during the COVID-19 pandemic. Multidisciplinary decision-making and a team approach for the unclear pathology with an emerging infectious disease was effective and contributed to the survival rate.

Background There are few agents that have been proven effective for COVID-19. Predicting clinical improvement as well as mortality or severity is very important. Objectives This study aimed to investigate the factors associated with the clinical improvement of COVID-19. Methods Overall, 74 patients receiving treatment for COVID-19 at Tokyo Medical and Dental University Hospital from April 6th to May 15th, 2020 were included in this study. Clinical improvement was evaluated, which defined as the decline of two levels on a six-point ordinal scale of clinical status or discharge alive from the hospital within 28 days after admission. The clinical courses were particularly investigated and the factors related to time to clinical improvement were analyzed with the log-rank test and the Cox proportional hazard model. Results Forty-nine patients required oxygen support during hospitalization, 22 patients required invasive mechanical ventilation, and 5 patients required extracorporeal membrane oxygenation. A total of 83% of cases reached clinical improvement. Longer period of time from onset to admission (≥10 days) (HR, 1.057; 95% CI, 1.002–1.114), no hypertension (HR, 2.077; 95% CI, 1.006–4.287), and low D-dimer levels (

The combination of extracorporeal membrane oxygenation with lung‐protective ventilation strategies could be a potential treatment option for intractable pneumothorax with coronavirus disease 2019 (COVID‐19) to avoid unnecessary surgical procedures and aerosol generation., Background Some patients with coronavirus disease 2019 (COVID‐19) develop pneumothorax. Tube thoracotomy and bulla resection could generate aerosols and cause virus transmission; the optimal treatment strategy remains unclear. Case Presentation A 57‐year‐old male was transferred as a severe COVID‐19 pneumonia case. On the 16th day after admission, the patient’s respiratory condition deteriorated, and the chest X‐ray revealed the presence of severe right‐sided pneumothorax. A chest drain was immediately inserted; however, a significant air leak continued, and severe ventilator settings were required. Thus, veno‐venous extracorporeal membrane oxygenation (VV‐ECMO) treatment was initiated to allow the lungs to rest. After 10 days of lung‐protective ventilation, the patient was weaned from ECMO and the chest drain was removed on the following day with no major comorbidities. Conclusion The combination of ECMO with lung rest strategy could be a treatment option for intractable pneumothorax with COVID‐19 to avoid unnecessary surgical procedures and aerosol generation.

Background The bridge-to-bridge (BTB) strategy, a conversion to durable left ventricular assist device (LVAD) after stabilization using surgical temporary mechanical circulatory supports for a couple of months, is not uncommon in Japan. However, its effect on clinical outcomes in comparison with a primary durable LVAD implantation strategy remains unknown.Methods and Results:Data of 837 consecutive patients (median age 45, 73% males) who underwent durable LVAD implantation as BTB (n=168) or primary implant (n=669) between April 2011 and April 2019 were retrospectively reviewed from the prospective multicenter Japanese mechanically assisted circulatory support registry. The BTB group was younger and had comparable end-organ function, better hemodynamic profile, and longer operative time compared with the primary implant group at baseline. The 3-year survival was 80% vs. 87% (P=0.007) for the BTB and primary implant groups respectively, with greater observed rates of stroke and infection as the predominant causes of death. The BTB strategy was independently associated with increased 3-year mortality (hazard ratio 2.69 [1.43-5.07], P=0.002) in addition to other significant risk factors. Conclusions The BTB cohort had comparable baseline characteristics to the primary implant cohort at the time of durable LVAD conversion, but had lower 3-year survival. Detailed analysis clarifying the causality of this finding should improve outcomes with the BTB strategy.

Background: Left ventricular assist device (LVAD) therapy has improved the clinical outcomes in advanced heart failure patients, however, this may differ between countries. We aimed to compare outcomes between Japanese and US LVAD cohorts. Methods: For 416 consecutive LVAD patients who received HeartMate II LVAD implantation and completed a one-year follow-up, age-matched Japanese patients (the Japanese registry for mechanically assisted circulatory support (J-MACS) group) and the US patients were compared for their clinical outcomes. Results: 154 J-MACS patients and 77 US patients were compared. Survival, free from hemocompatibility-related adverse events (HRAEs) in the J-MACS was statistically comparable with the US (75% vs. 63%, p = 0.79). J-MACS had more disabling strokes than the US (0.221 vs. 0.052/patient-year, p = 0.005), whereas there was less nonsurgical bleeding (0.045 vs. 0.117/patient-year, p = 0.024). The net hemocompatibility score was statistically comparable between the groups (1.54 vs. 1.19 points/patient, p = 0.99). Post-LVAD prothrombin time with international normalized ratio (INR) &lt, 1.5 (odds ratio 4.07) was a risk factor for HRAEs in J-MACS, whereas INR &gt, 3.0 (odds ratio 5.71) was a risk factor in the US (p &lt, 0.05 for both). Conclusion: In the age-matched cohorts, the J-MACS group experienced more strokes, while the US group had more bleedings. &ldquo, Tailor-made&rdquo, therapeutic strategy might be required for each country, given the unique variation of HRAE incidence among each country.

Background Tricuspid valve (TV) geometry gained attention when the prognostic significance of tricuspid regurgitation (TR) was determined. However, the TV geometric characteristics in Barlow disease (BD) have not been elucidated. This study aimed to clarify the difference in TV morphology between BD and fibroelastic deficiency (FED) and the effect of its geometry on residual TR after tricuspid annuloplasty (TAP) using three-dimensional (3D) transesophageal echocardiography. Methods Based on the mitral valve (MV) morphology defined by 3D transesophageal echocardiography, 106 patients with degenerative MV disease were classified into BD (n = 42) and FED (n = 64). Three-dimensional images of the TV were analyzed using a quantification software to compare the geometrical parameters. Among them, 35 patients (17 with BD and 18 with FED) underwent concomitant TAP during MV surgery, and the residual TR after TAP was evaluated within 1 month. Results TV annulus area, billowing height, and billowing volume were greater in BD than in FED (10.8 ± 2.9 vs 9.2 ± 2.4 cm2, 4.6 ± 1.6 vs 2.3 ± 1.1 mm, and 1.3 ± 0.8 vs 0.3 ± 0.3 mL; all P Conclusions Patients with BD exhibited larger TV annulus area and billowing than FED patients. These results suggest that degenerative changes in the TV apparatus in BD patients are similar to that seen in the MV apparatus. These findings should be taken into consideration when a TV surgery is required.

Although the mechanism of systolic anterior motion (SAM) of the mitral valve is unknown, it is known to have a multifactorial pathophysiology. Echocardiographic analysis of the mitral leaflet revealed the step-wise progression of SAM, and intraventricular flow analysis revealed the contribution of drag force generated by the misled flow below the posterior leaflet. Although several diverse clinical features of SAM are already known, some key features need to be abstracted from among them to understand the regulation of SAM establishment. This paper reviews past articles that have investigated the mechanism of SAM and proposes a mechanism-based concept to provide insights for better comprehension of SAM recognition.

Purpose Left ventricular assist devices (LVADs) have emerged as an important treatment option for bridging patients with heart failure to transplant. LVADs have shown improved survival; however, the impact of LVAD type on the quality of life (QoL) while on long-term LVAD support is unknown. We aimed to evaluate the QoL of patients while supported with a LVAD in Japan. Methods 299 patients enrolled in the Japanese Registry for Mechanically Assisted Circulatory Support (J-MACS), who were listed for transplant or likely to be listed, received a LVAD from 2010 to 2018 and had full QoL data, were enrolled. QoL data, such as visual analogue scale (VAS) and EQ-5D-3L by 5 dimensions (5D: mobility, self-care, usual activities, pain/discomfort and anxiety/depression) before and at 3- and 12-months after implantation of a LVAD were obtained from the J-MACS Registry. These patients were divided into 3 groups; primary implantable LVAD (iLVAD) (N=263), primary paracorporeal LVAD (pLVAD) (N=9) and bridge from paracorporeal to implantable LVAD (BTB) (N=27). Results VAS in all groups significantly increased from before to 3- and 12-months after LVAD implantation(p Conclusion QoL as VAS and 5D were significantly improved after implantation of any LVAD type. However, VAS and 5D except anxiety/depression in patients with pLVAD were significantly lower and more problems than those in patients with iLVAD. These differences were eliminated by converting from pLVAD to iLVAD. BTB might be a beneficial treatment option to improve QoL as well as patient's survival.

Although aortic valve-sparing operations are performed throughout Japan, the indications, specific repair techniques, and outcomes have not been reported in full. Thus, we conducted the first nationwide survey of aortic valve-sparing surgery. We mailed a questionnaire to 508 institutions across Japan to obtain information on elective aortic valve and aortic root surgeries performed in 2014. Included in the mailing was a secondary questionnaire that sought further information from institutions reporting aortic valve-sparing surgeries. Two hundred and fifty (49%) institutions responded and reported a total of 7859 aortic valve operations and 771 aortic root operations. Aortic valve operations performed strictly for aortic regurgitation totaled 2080, 156 (8%) of which were aortic valve repairs. Of the 699 aortic root surgeries performed for aortic regurgitation, 236 (34%) were valve-sparing root replacement surgeries. The valve-sparing root replacement surgeries comprised aortic valve reimplantation (n = 173, 73%) and aortic root remodeling (n = 63, 27%). Five of 57 (9%) institutions were responsible for 42% (99/233) of the total aortic valve-sparing surgeries performed. Detailed information that was obtained for 233 patients who underwent aortic valve repair or valve-sparing root replacement showed 30-day mortality and reoperation for regurgitation after aortic valve repair (n = 97), aortic root remodeling (n = 37), and aortic valve reimplantation (n = 99) to be 1, 0, and 1% and 3, 3, and 1%, respectively. To date, aortic valve-sparing operations have been performed for limited patients at limited institution in Japan, but the early outcomes have been excellent.

The online version of the original article can be found under doi: 10.1007/s11748-015-0590-3 .

A 44-year-old man presented with an abnormal chest shadow. Computed tomography-guided biopsy showed a chondral tumor of the thoracic vertebrae. Five years later, he developed a walking disorder, left leg numbness, and a vesicorectal disorder. Emergency orthopedic spinal decompression was performed. Eight months later, the residual tumor had become larger and was adjacent to the aorta. Prior to thoracotomy, an intraaortic stent was inserted. The 4th and 5th ribs were invaded by the tumor. The entire tumor and chest wall were excised with the aortic adventitia. The tumor was diagnosed as a low-grade chondrosarcoma of the thoracic vertebrae.

Background: Genome-wide association studies (GWAS) have identified numerous loci associated with diseases and traits. However, the elucidation of disease mechanisms followed by drug development has remained a challenge owing to complex gene interactions. We performed pathway analysis with MAGENTA (Meta-Analysis Geneset Enrichment of variaNT Associations) to clarify the pathways in genetic background of AF. Methods: The existing GWAS data were analyzed using MAGENTA. A microarray analysis was then performed for the identified pathways with human atrial tissues, followed by Gene-Set Enrichment Analysis (GSEA). Results: MAGENTA identified two novel candidate pathways for AF pathogenesis, the CTCF (CCCTC-binding factor, p = 1.00 × 10−4, FDR q = 1.64 × 10−2) and mTOR pathways (mammalian target of rapamycin, p = 3.00 × 10−4, FDR q = 3.13 × 10−2). The microarray analysis with human atrial tissue using the GSEA indicated that the mTOR pathway was suppressed in AF cases compared with non-AF cases, validating the MAGENTA results, but not CTCF pathway. Conclusions: MAGENTA identified a novel pathway, mTOR, followed by GSEA with human atrial tissue samples. mTOR pathway is a key interface that adapts the change of environments by pressure overload and metabolic perturbation. Our results indicate that the MTOR pathway is involved in the pathogenesis of AF, although the details of the basic mechanism remain unknown and further analysis for causal-relationship of mTOR pathway to AF is required. CTCF pathway is essential for construction of chromatin structure and transcriptional process. The gene-set components of CTCF overlap with those of mTOR in Biocarta. Keywords: Atrial fibrillation, Pathway analysis, mTOR, MAGENTA, Transcriptome analysis

Background The Japanese registry for mechanical assisted circulatory support (J-MACS) is a prospective registry to collect all data of implantable left ventricular assist device (LVAD) (and part of paracorporeal VAD) established in 2010. The first analytical report was published in 2017. The organization running J-MACS was used to be the pharmaceuticals and medical devices agency (PMDA), but has been changed to the council for clinical use of ventricular assist device related academic societies in 2017. Methods Since 2018, we changed the analytical methods as follows: first, we eliminated paracorporeal VAD from the analysis. Second, we included not only primary implantation but bridge to bridge (BTB) implantation of LVAD. Third, we added the analyses of adverse events that were not included in the previous analysis. Results As of Oct 2018, 711 primary LVAD implants and 168 BTB implants were enrolled. Survival rate of primary LVAD was 93% at 360 days and 91% at 720 days, and that of BTB was 86% at 360 days and 82% at 720 days. Conclusion We first reported the results of BTB in the second official report of J-MACS. The prognosis after LVAD implantation has been kept good in Japanese circumstances.

There is uncertainty over the efficacy of additional surgical ventricular reconstruction (SVR) associated with mitral valve operation for non-ischaemic dilated cardiomyopathy (DCM). This study aims to assess mid-term outcomes of these non-heart transplant surgical approaches for DCM. We reviewed retrospectively 106 patients (median age 64, 44 females) who underwent isolated mitral annular plasty (MAP; n = 34), mitral valve replacement (MVR; n = 29), and SVR associated with MAP (SVR + MAP; n = 43) for DCM, in 11 Japanese hospitals. We analysed mid-term outcomes, specifically freedom from cardiac death and cardiac event. Hospital deaths occurred in 16 patients (15.1%) and cardiac deaths in 36 patients (34.0%) during the study period of 4.4 ± 3.5 years. Freedom from cardiac death at 7 years in patients undergoing MAP, MVR, and SVR + MAP were, respectively, 79.1%, 82.6%, and 29.5% (P

Surgery for obstructive hypertrophic cardiomyopathy with mitral abnormality requires a combined procedure of myectomy and mitral leaflet plication for relieving mitral systolic anterior motion and left ventricular outflow tract obstruction. We report a combined procedure of myectomy using intracardiac high-resolution ultrasonography and mitral bileaflet shortening in obstructive hypertrophic cardiomyopathy. Stepwise real-time verification of residual ventricular mass using high-resolution ultrasonic probe would be a potent addition to our armamentarium. This modality provides safe and effective myectomy, which has been a most technically challenging surgical procedure especially for inexperienced surgeons.

This chapter discusses the characteristics and problems of aortic valve replacement in young patients and the advantages and disadvantages of aortic valvuloplasty, focusing on young patients who have completed their physical growth.

The aim of the study was to evaluate the disposition of plasma unbound cefazolin in patients undergoing cardiothoracic surgery with cardiopulmonary bypass (CPB). Adult patients undergoing cardiothoracic surgery with CPB were enrolled in the study. Cefazolin sodium was given intravenously before skin incision (1 g) and at the beginning of CPB (2 g). Thereafter, an additional dose (1 g) was given every 4 hours. Seven to ten blood samples were collected before and during surgery. Plasma total and unbound (ultrafiltrated) cefazolin concentrations were analyzed using an HPLC‐UV method. Plasma protein binding was analyzed with the Langmuir model. Twenty‐seven patients (aged 70 ± 12 years, body weight 62 ± 12 kg, mean ± SD) with GFR >30 mL min−1 completed the study. There was a significant (P

Off-pump coronary artery bypass grafting (OPCAB) in patients with acute myocardial infarction (AMI) is difficult because of circulatory deterioration during displacement of the heart. At our institution, we performed minimally circulatory-assisted on-pump beating coronary artery bypass grafting (MICAB) in these patients. During MICAB, support flow was controlled at a minimal level to maintain a systemic blood pressure of approximately 100 mm Hg and a pulmonary arterial systolic pressure of

The Japanese Association for Thoracic Surgery has conducted annual surveys of thoracic surgery throughout Japan since 1986 to determine the statistics regarding the number of procedures according to operative category. Here, we have summarized the results from our annual survey of thoracic surgery performed during 2013. The incidence of hospital mortality was added to the survey to determine the nationwide status, which has contributed to the Japanese surgeons to understand the present status of thoracic surgery in Japan and to make progress to improve operative results by comparing their work with those of others. The Association was able to gain a better understanding of present problems as well as future prospects, which has been reflected to its activity including education of its members. Thirty-day mortality (so called “operative mortality”) is defined as death within 30 days of operation regardless of the patient’s geographic location and even though the patient had been discharged from the hospital. Hospital mortality is defined as death within any time interval after an operation if the patient had not been discharged from the hospital. Hospital-to-hospital transfer is not considered discharge: transfer to a nursing home or a rehabilitation unit is considered hospital discharge unless the patient subsequently dies of complications of the operation. (The definitions of the Ad Hoc Liaison Committee for Standardizing Definitions of Prosthetic Heart Valve Morbidity of the Society of Thoracic Surgeons and the American Association for Thoracic Surgery (Edmunds et al. Ann Thorac Surg 1996;62:932–5; J Thorac Cardiovasc Surg 1996;112:708–11). Thoracic surgery was classified into three categories—cardiovascular, general thoracic, and esophageal surgery—and the patient data were examined and analyzed for each group. Access to the computerized data is offered to all members of this Association. We honor and value all member’s continued kind support and contributions (Tables 1, ​,22). Table 1 Questionnaires sent out and received back by the end of December 2014 Table 2 Categories subclassified according to the number of operations performed

In the 1990s, epicardial implantable cardioverter-defibrillator (ICD) patches were frequently implanted to treat life-threatening ventricular arrhythmia. However, owing to the high rates of functional failure, the patch system has been replaced by transvenous ICD leads system. Although morphological abnormalities such as dense fibrosis around the patch are quite frequent, epicardial ICD patch-induced localized constrictive pericarditis is very rare. We encountered a patient who had severe heart failure due to constrictive pericarditis, 23 years after the implantation of epicardial ICD patches. The heart failure was treated after complete resection of the patches and dense fibrosis on the surface of both the right and the left ventricles. To our knowledge, this is the first report on the treatment of epicardial ICD patch-induced localized constrictive pericarditis.

Patient: Female, 30-year-old Final Diagnosis: Severe COVID-19 pneumonia Symptoms: Dyspena Medication: — Clinical Procedure: Extracorporeal membrane oxygenation Specialty: Critical Care Medicine • Infectious Diseases Objective: Unusual clinical course Background: There are few reports of coronavirus disease 2019 (COVID-19) in pregnant women. Although coagulation dys-function was reported to affect the severity of COVID-19, the association between pregnancy, which is usually accompanied by changes in coagulation function, and the worsening of COVID-19 is unknown. We present a case of a 30-year-old woman in the 36th week of pregnancy who was diagnosed with severe COVID-19 pneumonia and required postpartum extracorporeal membrane oxygenation (ECMO) therapy. Case Report: A 30-year-old, 36-weeks pregnant woman presented to our hospital and was diagnosed with severe COVID-19 pneumonia soon after she had undergone a cesarean section. Her respiratory failure could not be managed by conventional therapeutic approaches. Therefore, ECMO was administered on day 7. Controlling coagulation function to maintain ECMO therapy was challenging. Nafamostat mesylate and cryoprecipitate were administered to treat the hypercoagulative status and severe hypofibrinogenemia, respectively. Since coagulopathy and her respiratory state improved, the ECMO therapy was terminated on day 15. Conclusions: We report a case of severe COVID-19 pneumonia in a pregnant woman urgently treated with ECMO in the post-partum period. Thus, this case highlights the importance of close monitoring and appropriate medical care for pregnant women with severe COVID-19 pneumonia.

Background Advanced age has an adverse impact on clinical results in left ventricular assist device (LVAD) patients. We compared the clinical results of patients aged >60 years with younger patients using a national Japanese database.Methods and Results:Between April 2013 and December 2016, 300 patients underwent HeartMateII implantation. Of these, 37 patients were ≥60 years at LVAD implantation, and the clinical results of these patients were compared with the other younger 263 patients. At 1 and 3 years the on-device survival was 95%, 91% in younger patients, and 85%, 75% in older patients, respectively (P=0.016), although age was not a risk factor on the multivariate analysis. There was no significant difference between the groups in incidence of various adverse events except stroke. In the propensity-matching cohort, the incidence of stroke was significantly higher in patients aged >60 years (P=0.047). In patients aged >60 years, improvement of renal function was transient and there was no improvement later than 3 months, and recovery of serum albumin level to preoperative value was delayed. Conclusions There were significant differences in the stroke incidence and recovery of end-organ functions after LVAD implantation. This may have important implications for patient selection in future destination therapy in Japan, where quality of life is an important issue in LVAD support.

Background The right gastroepiploic artery (GEA) is utilized as an excellent in situ arterial graft conduit to right coronary artery territory for coronary artery bypass grafting (CABG). However, there remain great concerns regarding the management of patients with a patent in situ GEA during abdominal surgery following CABG. Methods From 1995 to 2016, GEA was used for CABG in 278 patients at our institution. Of the patients, 14 abdominal surgeries were performed for subsequent abdominal diseases in 11 patients with a patent in situ GEA for CABG. We investigated the results of the surgeries and how to manage the GEAs in abdominal surgery. Results Laparotomy was required for gastric cancer in 3 patients, pancreatic cancer in 3, hepatic cancer in 2, cholangiocarcinoma in 1, duodenal papillary head cancer in 1, and cholecystitis in 1; multiple abdominal surgeries were needed in 2 patients for cancer recurrence and ileus. The intraabdominal adhesions around the GEAs were minimal in all patients. No graft injury occurred at the time of opening of the abdomen, and the planned procedures were completed without any circulatory problems. In 3 patients undergoing pancreaticoduodenectomy, intraabdominal off-pump rerouting of the GEA with a short saphenous vein was necessary for en bloc resection of the cancers and lymph nodes. There was neither operative mortality nor graft-related cardiac event except for 1 due to multiple organ failure. Conclusions Although intraabdominal rerouting of GEA is necessary for pancreaticoduodenectomy, abdominal surgery can be safely performed in patients with a patent in situ GEA coronary graft.

Mitral valve repair is the preferred surgical treatment for mitral regurgitation. Cardiac surgeons must increasingly pursue high-quality mitral valve repair, which ensures excellent long-term outcomes. Intraoperative assessment of a competency of the repaired mitral valve before closure of the atrium is an important step in accomplishing successful mitral valve repair. Saline test is the most simple and popular method to evaluate the repaired valve. In addition, an "Ink test" can provide confirmation of the surface of coaptation, which is often insufficient in the assessment of saline test. There are sometimes differences between the findings of the leakage test in an arrested heart and the echocardiographic findings after surgery. Assessment of the mitral valve in an arrested heart may not accurately reflect its function in a contractile heart. Assessment of the valve on the beating heart induced by antegrade or retrograde coronary artery perfusion can provide a more physiological assessment of the repaired valve. Perfusion techniques during beating heart surgery mainly include antegrade coronary artery perfusion without aortic cross-clamping, and retrograde coronary artery perfusion via the coronary sinus with aortic cross-clamping. It is the most important point for the former approach to avoid air embolism with such precaution as CO2 insufflation, left ventricular venting, and transesophageal echocardiography, and for the latter approach to maintain high perfusion flow rate of coronary sinus and adequate venting. Leakage test during mitral valve repair increasingly takes an important role in successful mitral valve reconstruction.

Purpose Background: Survival rates for patients requiring extracorporeal membrane oxygenation (ECMO) support due to cardiogenic shock remain poor because of difficulties in decision making on optical timing of ECMO removal or conversion to ventricular assist devices (VAD). Methods From 2005 to 2018, 37 patients supported with ECMO due to circulatory deterioration were referred to our institution for implantation of VAD. The outcomes were analyzed using multi-variate analysis to assess the risk factors of VAD implantation, and we adopted a decision-tree to improve the outcomes. Results Six patients were withdrawn from VAD therapy due to stroke and infection. ECMO could be removed in 6 patients (6.1 days of ECMO support), but one of them was estimated to need VAD support due to the IABP-dependent circulatory condition. In total, 26 patients needed VAD support after 5.7 days of ECMO support. Four of them reached to heart transplantation, and VAD was explanted in 2 patients. Six patients remain on VAD. Statistically significant risk factors by multi-variate analysis on 2-year mortality were preoperative renal replacement (p=0.006) and T.Bil (p=0.051, Threshold 4.0 mg/dl). Two-year survival of patients without end-organ dysfunction as mentioned above was excellent (83.3%). However, that of patients with end-organ dysfunction was miserable (23.1%). Based on these findings, we applied to a following decision-tree. Step I: end-organ dysfunction; if yes, additional introduction of more effective circulatory support with left ventricular venting. Step II: aortic valve opening: if no, emergent/urgent VAD implantation. If yes, wait for cardiac functional recovery on ECMO. Step III: cardiac function; if no recovery, VAD implantation, and if recovered, ECMO removal. Since this decision-tree was applied, ECMO support was initiated in four patients with end-organ dysfunction before VAD implantation. After T.Bil decreased from 15.9mg/dl to 4.6 mg/dl and the value of Creatinine from 4.0 mg/dl to 1.5mg/dl, those patients underwent VAD implantation and survived. Conclusion Our experiences of salvage from ECMO suggest that preoperative renal replacement and T.Bil less than 4.0 mg/dl was a strong risk factor for mid-term mortality. For those patients, recovery from end-organ dysfunction before VAD implantation is essential.

Objectives: The postoperative left ventricular end-systolic volume index and ejection fraction are benchmarks of surgical ventricular reconstruction but remain unpredictable. This study aimed to identify who could be associated with a higher long-term survival by adding surgical ventricular reconstruction to coronary artery bypass grafting than coronary artery bypass grafting alone (responders to surgical ventricular reconstruction). Methods: The subjects were 293 patients (median age, 63 years; 255 men) who underwent coronary artery bypass grafting for ischemic heart disease with left ventricular dysfunction in 16 cardiovascular centers in Japan. The relationships among surgical ventricular reconstruction, postoperative end-systolic volume index, ejection fraction, and survival were analyzed to identify responders to surgical ventricular reconstruction. Results: Surgical ventricular reconstruction was performed in 165 patients (56%). The end-systolic volume index and ejection fraction significantly improved (end-systolic volume index, 91 to 64 mL/m2; ejection fraction, 28% to 35%) for all patients. The postoperative end-systolic volume index and ejection fraction were estimated, and surgical ventricular reconstruction was found to be significantly associated with both end-systolic volume index (14.5 mL/m2 reduction, P < .001) and ejection fraction (3.1% increase, P = .003). During the median follow-up of 6.8 years, 69 patients (24%) died. Only the postoperative ejection fraction was significantly associated with survival (hazard ratio, 0.925; 95% confidence interval, 0.885-0.968), although this effect was limited to those with postoperative end-systolic volume index of 40 to 80 mL/m2 in the subgroup analysis (hazard ratio, 0.932; 95% confidence interval, 0.894-0.973). Conclusions: Adding surgical ventricular reconstruction to coronary artery bypass grafting could reduce the mortality risk by increasing ejection fraction for those with a postoperative end-systolic volume index within a specific range. The postoperative end-systolic volume index could demarcate responders to surgical ventricular reconstruction, and its estimation can help in surgical decision making.

Techniques used in hybrid repair of proximal aortic arch diseases are associated with perioperative complications such as cerebrovascular emboli. We present an easy and safe technique of total debranching thoracic endovascular aortic repair for arch diseases using axilloaxillary arterial bypass. The placement of the axilloaxillary arterial bypass enables perfusion of the brachiocephalic artery even when the artery is clamped. After reconstruction of the brachiocephalic artery and the left common carotid artery, the left subclavian artery is proximally ligated, and it is perfused through the bypass. This procedure is simple, safe, and useful for the prevention of neurologic complications.

Annual report by The Japanese Association for Thoracic Surgery: Committee for Scientific Affair Munetaka Masuda, Hiroyuki Kuwano and Meinoshin Okumura have contributed equally.

Short- to mid-term extracorporeal ventricular assist devices (VADs) are recommended for critical cardiogenic shock patients. We have designed a preclinical, single-use MedTech Mag-Lev VAD for one-month extracorporeal use. The impeller-rotor of the pump was suspended by a two degree-of-freedom active magnetic bearing in a 300 μm fluid gap, where the computational fluid dynamics analysis predicted a secondary flow of about 400-500 ml/min at a pump speed of 1800-2200 rpm. Three eddy current sensors were employed to implement noise- and drift-free magnetic levitation. The pump components were injection molded using polycarbonate for smooth surfaces as well as improved reproducibility, followed by coating with a biocompatible 2-methacryloyl-oxyethyl phosphorylcholine polymer. Chronic animal experiments were performed in nine calves. Three of the nine calves were excluded from analysis for problems with the circuit. Five of the six (83.3%) completed the 60 day duration of the study, while one prematurely died of massive bleeding due to inflow port detachment. The pump did not stop due to magnetic-levitation malfunction. Neither pump thrombosis nor major organ infarction was observed at autopsy. In comparison to machined surfaces, the injection-molded pump surfaces were thrombus-free after 60 day implantation. This study demonstrates the feasibility of MedTech Mag-Lev VAD for 60 day circulatory support.