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This study aimed to examine the educational challenges faced by perfusionists in Japan. Although Japan has over 400 cardiovascular surgery centers, it performs fewer surgeries than by countries such as Germany and the United States. We focused on challenges related to varying caseloads and working conditions.We conducted an online survey containing 24 questions using Google Forms from January to June 2022, targeting perfusionists in Japan. The 24-question survey spanned various educational topics and was approved by the Morinomiya University of Medical Sciences Ethics Committee.Responses were received from 129 perfusionists across 77 institutions. Approximately 70% of these centers managed less than 200 cardiopulmonary bypass (CPB) cases per year, with a similar proportion of perfusionists handling under 50 CPB cases annually. Challenges in Japanese perfusionist education include enhancing communication and troubleshooting skills and the need for instructors with a broad teaching experience.This study emphasizes the significant differences in caseload and work environments for perfusionists among Japanese institutions. Perfusionists, who often work in clinical engineering, have various responsibilities. These findings highlight the need for improved communication, problem-solving skills, and the implementation of modern teaching technologies. Additionally, this study highlights the complexities of training Japanese perfusionists and underscores the need for more practical, technology-driven educational methods. Addressing these issues is crucial for improving Japan’s healthcare standards and could influence global perfusionist education. [ABSTRACT FROM AUTHOR]

OBJECTIVE Impact of the decrease of regional cerebral oxygen saturation (rSO2) on postoperative delayed awakening after total aortic arch replacement (TAR) was validated. METHODS From 2008 to 2013, 143 consecutive patients underwent TAR using selective antegrade cerebral perfusion. rSO2 was monitored using near-infrared spectroscopy. We calculated a percent decrease of rSO2 (%-D) immediately after rewarming according to the following formula: %-D = rSO2 (X1) − rSO2 (X2)/rSO2 (X1) × 100 (%), where rSO2 (X1) was measured at the beginning of rewarming, and rSO2 (X2) was measured 10 min later. Delayed awakening was defined as patients not waking up for more than 6 h after the termination of anaesthesia. RESULTS The average time to wake up was 3.6 ± 2.0 h. Fourteen patients showed delayed awakening. %-D showed a positive linear relationship to awakening time (y = 0.67x − 0.7, r = 0.23, P = 0.007) and receiver operating characteristic analysis showed %-D had a good predictive value for delayed awakening (area under the curve = 0.84). %-D was significantly different between the delayed awakening and the normal group (7.1 ± 5.1 vs 1.3 ± 6.6%, P = 0.002). Two patients (1.4%) who had multicomorbidity with higher %-D died in the hospital due to colon necrosis and sepsis. There were significant differences between patients with normal and delayed awakening in hospital mortality (P = 0.04) and transient neurological deficit (TND, P = 0.007). CONCLUSION The maintenance of rSO2 at the early phase of rewarming may be important to avoid delayed awakening or TND after TAR. [ABSTRACT FROM PUBLISHER]

OBJECTIVES We present our experience of total aortic arch replacement. METHODS Twenty-nine patients (21 males and 8 females; mean age 63.3 ± 13.3 years) with extended thoracic aortic aneurysms underwent graft replacement. The pathology of the diseased aorta was non-dissecting aneurysm in 11 patients, including one aortitis and aortic dissection in 18 patients (acute type A: one, chronic type A: 11, chronic type B: six). Five patients had Marfan syndrome. In their previous operation, two patients had undergone the Bentall procedure, three had endovascular stenting, one had aortic root replacement with valve sparing and 12 had hemi-arch replacement for acute type A dissection. Approaches to the aneurysm were as follows: posterolateral thoracotomy with rib-cross incision in 16, posterolateral thoracotomy extended to the retroperitoneal abdominal aorta in seven, mid-sternotomy and left pleurotomy in three, anterolateral thoracotomy with partial lower sternotomy in two and clam-shell incision in one patient. Extension of aortic replacement was performed from the aortic root to the descending aorta in 4, from the ascending aorta to the descending aorta in 17 and from the ascending to the abdominal aorta in eight patients. Arterial inflow for cardiopulmonary bypass consisted of the femoral artery in 15 patients, ascending aorta and femoral artery in seven, descending or abdominal aorta in five and ascending aorta in two. Venous drainage site was the femoral vein in 10, pulmonary artery in eight, right atrium in five, femoral artery with right atrium/pulmonary artery in four and pulmonary artery with right atrium in two patients. RESULTS The operative mortality, 30-day mortality and hospital mortality was one (cardiac arrest due to aneurysm rupture), one (rupture of infected aneurysm) and one (brain contusion), respectively. Late mortality occurred in three patients due to pneumonia, ruptured residual aneurysm and intracranial bleeding. Actuarial survival at 5 years after the operations was 80.6 ± 9.0%. Freedom from the subsequent aortic events was 96.0 ± 3.9% at 5 years. CONCLUSIONS Our treatment method for extensive thoracic aneurysms achieved satisfactory results using specific strategies and appropriate organ protection according to the aneurysm extension in the selected patients. [ABSTRACT FROM AUTHOR]

Introduction: Intestinal fatty acid-binding protein (I-FABP) is increasingly employed as a highly specific marker of intestinal necrosis. However, the value of this marker associated with cardiovascular surgery with hypothermic circulatory arrest is unclear. The aim of this study was to measure serum I-FABP levels and provide the transition of I-FABP levels with hypothermic circulatory arrest to help in the management of intestinal perfusion., Methods: From August 2011 to September 2013, 33 consecutive patients who had aortic arch surgery with hypothermic circulatory arrest or heart valve surgery performed were enrolled in the study. Twenty patients had aortic surgery with hypothermic (23-29°C) circulatory arrest and 13 patients had heart valve surgery with cardiopulmonary bypass (33°C)., Results: I-FABP levels increased, both in patients undergoing aortic surgery with hypothermic circulatory arrest and heart valve surgery with cardiopulmonary bypass, reaching peak levels shortly after the administration of protamine. I-FABP levels in patients with aortic surgery were significantly higher with circulatory arrest. They reached peak levels immediately after recirculation and there was a significant drop at the end of surgery (p<0.001). I-FABP levels in heart valve surgery were gradually increased, with the highest at the administration of protamine; they gradually decreased. Peak I-FABP levels were significantly higher in patients undergoing aortic surgery with hypothermic circulatory arrest than in patients with heart valve surgery. However, no postoperative reperfusion injury occurred in the intestinal tract due to the use of hypothermic organ protection., Conclusion: Plasma I-FABP monitoring could be a valuable method for finding an intestinal ischemia in patients with cardiovascular surgery.

Objectives: The goal of this study was to evaluate early and late outcomes of combined valve-sparing aortic root replacement and total arch replacement (TAR)., Methods: From October 1999 to May 2014, 195 patients underwent valve-sparing operations using the David reimplantation technique. Thirty-one patients underwent combined TAR for aortic regurgitation (AR) with extended aortic aneurysm from the aortic root to the aortic arch. Aetiologies included acute type A aortic dissection in 12 cases, chronic aortic dissection in 8 cases and non-dissecting aneurysm in 11 cases. There were 9 patients with Marfan syndrome. The preoperative severity of AR was mild in 4, moderate in 16 and severe in 11. Even though half of those were emergent operations for acute aortic dissection, preoperative haemodynamic conditions were stable in all patients., Results: No hospital deaths occurred. Postoperative complications included prolonged mechanical ventilation (>48 h) in 1 case and re-exploration for bleeding in 2 cases. Other complications, such as neurological dysfunction or low cardiac output syndrome, were not observed. At hospital discharge, 2 patients had mild AR, 22 had trace AR and 7 had no AR. During follow-up, 2 patients had moderate AR, 7 had mild AR, 18 had trace AR and 3 had no AR. Follow-up was completed in 95.1% of patients, and the mean follow-up period was 60.5 ± 9.1 months. No late death and thromboembolic complication occurred during follow-up. One patient required reoperation for AR. Freedom from reoperation at 5 and 10 years was 100 ± 0 and 83.3 ± 3.5%, respectively. Freedom from moderate or severe AR at 3 and 5 years was 83.3 ± 3.5 and 83.3 ± 3.5%, respectively., Conclusions: Early outcomes of combined aortic root reimplantation and TAR were satisfactory and provided excellent freedom from thromboembolic complication. The rate of freedom from reoperation during long-term follow-up was acceptable. Further follow-up is required to evaluate this procedure., (© The Author 2014. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background and Aim of the Study: Recent brain complications (e.g., bleeding or infarction) in patients with active infective endocarditis (AIE) are recognized as a contraindication for early surgery. Nafamostat mesilate (NM) is a synthetic protease-inhibiting agent that has not only potent inhibitory activity against coagulation factors (Xlla, Xa) but also an anti-inflammatory action. Herein is reported the authors' successful surgical experience using NM with low-dose heparinization in patients with AIE complicated by recent cerebral complications., Methods: Twenty-eight patients (mean age 54.9 +/- 18.7 years) who had undergone surgery for AIE of the native valve (n = 21) or prosthetic valve (n = 7) were reviewed retrospectively. AIE was present in the aortic (n = 8), mitral (n = 16), aortic/mitral (n = 4) and tricuspid (n = 1) valves. Twenty-two of 28 patients had preoperative stroke, and six had active brain bleeding. Surgery was performed at a mean of 2.4 +/- 2.1 days after the onset of stroke. NM (209 +/- 152 mg) with low-dose heparin (3796 +/- 1218 IU; 67.4 +/- 20.3 IU/kg) was used for anticoagulation during cardiopulmonary bypass (CPB). The activated clotting time (ACT) was maintained at 350-450 s by the precise administration of NM into a cardiotomy reservoir (0.5 mg/kg/h) and a venous reservoir (sliding controlled dose at 1.5 mg/kg/h)., Results: The CPB time was 181.3 +/- 92.6 min. Five patients (17.8%) died during hospitalization due to persistent sepsis (n = 3), brain death caused by massive brain embolism before CPB establishment (n = 1), and pneumonia (n = 1). There was no further aggravation of intracranial bleeding, and no new hemorrhagic stroke., Conclusion: Nafamostat mesilate, administered in conjunction with low-dose heparinization, served as an effective anticoagulant for early surgery in patients with AIE complicated by stroke, and caused no further deterioration of the cerebral lesions.

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: Optimal neuro-protection strategy in aortic arch surgery is a controversial issue. The present study reported surgical outcomes of total arch replacement using selective antegrade cerebral perfusion (SACP)., Methods: From January 2002 to December 2012, 438 consecutive patients (mean age 69.1±13.4 years) underwent total arch replacement using SACP through a median sternotomy. Acute aortic dissection was present in 86 patients (18.3; 80 type A, 6 type B) and shaggy aorta in 36 (8.2%). Emergent/urgent surgery was required in 144 (32.9%). Our current approach included: (I) meticulous selection of arterial cannulation site and type of arterial cannula; (II) selective antegrade cerebral perfusion; (III) maintenance of minimal tympanic temperature between 20 and 23 °C; (IV) early re-warming after distal anastomosis; and (V) maintaining fluid balance below 1,000 mL during cardiopulmonary bypass. A woven Dacron four branch graft was used in all patients., Results: Overall hospital mortality was 4.6% (20/438). Hospital mortality was 9.7% (14/144) in urgent/emergent surgery and 2.0% (6/294) in elective cases. Permanent neurological deficit occurred in 5.3% (23/438) of patients. Prolonged ventilation was necessary in 58 patients (13.2%). Multivariate analysis demonstrated that risk factors for hospital mortality were octogenarian (OR 4.45, P=0.03), brain malperfusion (OR 23.52, P=0.002) and cardiopulmonary bypass time (OR 1.07, P=0.04). The follow-up was completed in 97.9% with mean follow up of 2.3±2.3 years. Survival at 5 and 10 years after surgery was 79.6±3.3% and 71.2±5.0% respectively. In the acute type A dissection group, 10-year survival was 96.8±2.9%, while in the elective non-dissection group 5- and 10-year survival were 81.4±7.2% and 77.0±5.9% respectively., Conclusions: Our current approach for total aortic arch replacement utilizing SACP was associated with low hospital mortality and morbidities leading to favorable long-term outcome.

Technical details of our strategy for reconstructing the thoracoabdominal aorta are presented. Between October 1999 and June 2012, 152 patients underwent surgery for thoracoabdominal aortic aneurysms (Crawford classification type I =21, type II =43, type III =73, type IV =15). Mean age was 64.6±13.9 years. Sixty-three (41.4%) patients had aortic dissection, including acute type B dissection in 2 (1.2%) and ruptured aneurysms in 17 (11.2%). Eight (5.3%) patients had mycotic aneurysms, and 3 (2.0%) had aortitis. Emergent or urgent surgery was performed in 25 (16.4%) patients. Preoperative computed tomography (CT) scan or magnetic resonance (MR) angiography detected the Adamkiewicz artery in 103 (67.8%) patients. Cerebrospinal fluid drainage (CSFD) was performed in 115 (75.7%) patients and intraoperative motor evoked potentials were recorded in 97 (63.8%). One hundred and seven (70.4%) patients had reconstruction of the intercostal arteries from T7 to L2, 35 of which were reconstructed with the aortic patch technique and 72 with branched grafts. The mean number of reconstructed intercostal arteries was 3.1±2.5 pairs. Mild hypothermic partial cardiopulmonary bypass at 32-34 °C was used in 105 (69.1%) patients, left heart bypass was used in 4 (2.6%), and deep hypothermic cardiopulmonary bypass below 20 °C was used in 42 (27.6%). Thirty-day mortality was 9 (5.9%), and hospital mortality was 20 (13.2%). Independent risk factors for hospital mortality were emergency surgery (OR 13.4, P=0.003) and aortic cross clamping over 2 hours (OR 5.7, P=0.04). Postoperative spinal cord ischemia occurred in 16 (10.5%, 8 patients with paraplegia and 8 with paraparesis). Risk factors for developing spinal cord ischemic complications were prior surgery involving either the descending thoracic or the abdominal aorta (OR 3.75, P=0.05), diabetes mellitus (OR 5.49, P=0.03), and post-bypass hypotension <80 mmHg (OR 1.06, P=0.03). Postoperative survival at 5 years was 83.6±4.5%; 5-year survival was 47.5±8.6% in patients with spinal cord ischemia and 88.9±10.4% in those without spinal cord ischemia.