Retrograde cardioplegia is now an alternative or adjunctive method used worldwide as a cardiac protection during open heart surgery. However, its use involves some limitation. We operated on a patient suffering from aortic stenosis associated with PLSVC. During the operation on this patient for aortic valve replacement, retrograde infusion of cardioplegic solution could not be performed because the coronary sinus was excessively dilated and prevented the balloon from occluding it. Other anomalous lesion of the coronary sinus make the retrograde infusion of the cardioplegic solution difficult and these must always be kept in mind when cardioplegia is infused from the coronary sinus.

A 64-year-old man with a history of anterior blunt trauma 10 years previously was admitted to our hospital complaining of general fatigue. A plain chest roentgenogram showed pericardial calcification. Computed tomography and echocardiography showed the mass to be a calcified capsule in the anterior mediastinum compressing the right side of the heart. He underwent an operation through a median sternotomy. The mass was an organized hematoma encapsulated by a calcified fibrous and serous layer of the pericardium. The hematoma was resected together with the calcified pericardium under cardiopulmonary bypass. His postoperative course was uneventful. He had no history of hemopericardium but had experienced blunt chest trauma that seemed to have induced the subsequent localized constrictive pericarditis.

We report the case of a patient with severe tricuspid regurgitation and severe liver dysfunction who was successfully treated by tricuspid valve repair with spiral suspension and perioperative management of high cardiac output. The patient was a 77-year-old woman who presented with chronic atrial fibrillation with bradycardia (heart rate approximately 50 bpm). She had been diagnosed with severe tricuspid valve and mitral valve regurgitation at the age of 74. As her heart failure and hepatic failure grew worse, and hepatic encephalopathy also occurred, she was admitted to the hospital. Her Child-Pugh score for liver disease was Grade C at the preoperative assessment, suggesting that she was in the high-risk category for open heart surgery. Therefore, further medical treatment was required before selecting the surgical treatment. After the implantation of a pacemaker (VVI mode, 80 bpm), the cardiac output increased with a cardiac index of 5.17 L/min/m2 compared with 2.97 L/min/m2 prior to pacemaker implantation. Furthermore, the symptoms of heart failure improved and total bilirubin decreased from 3.9 mg/dl to 1.7 mg/dl, and surgery was performed. Tricuspid regurgitation was treated with spiral suspension, and mitral regurgitation due to annular dilation was treated with annuloplasty. Following the surgery, the cardiac index was maintained from 4.3 L/min/m2 to 5.8 L/min/m2 with central venous pressure below 10 mmHg by the assistance of intra-aortic balloon pumping. The patient was extubated 30 h after surgery, and was discharged on postoperative day 54. At the time of discharge, total bilirubin was 1.5 mg/dl. At 1.5 post-operative years, the patient is New York Heart Association functional Class II and tricuspid valve regurgitation is mild.

The Professionalism subcommittee of Japan Society for Medical Education has been examining a diverse range of issues related to medical professionalism education for approximately the past 20 years. In July 2015, the committee formulated and presented a draft on “ The Attributes and Competencies of Physicians: An Exploration of Professionalism” Based on this, we have been conducting educational activities on professionalism education, but we had not documented this draft. We are now re-presenting the draft here with minor lexical corrections and additional notes. The professionalism of physicians is delineated in seven attributes and competencies :1. Sense of mission and responsibility towards society2. Practice of patient-centered health care3. Demonstration of integrity and justice4. Acceptance of diverse values and sharing of fundamental values5. Fulfilling roles as leaders/members in organizations and teams6. Pursuit of excellence and lifelong learning7. Self-management and career developmentThis document is presented with the expectation that it will contribute to future discussions on professionalism education.