We experienced a case of extensively calcified mitral annulus and severe mitral regurgitation. A 75-year-old woman underwent successful debridement of an annular calcification with a CUSA^® and replacement of mitral valve with a MIRA^TM valve in a supra-annular position. Use of CUSA^® allowed safe removal of the calcification and prevented the tearing of the A-V groove vessels. In our technique, calcification is left to a certain extent to keep annular strength. Also the MIRA^TM valve has soft and rich sewing cuff, which enhances coaptation in highly calcified annuli and accommodates even fragile tissue. This makes it possible to implant valves even in severely diseased annulus conditions.

A 68-year-old man who had undergone previous coronary artery bypass grafting was admitted with cardiac failure because of aortic valve stenosis and severe mitral valve regurgitation. Preoperative cardiac catheterization showed a patent left internal thoracic artery (LITA) and a stenotic saphenous vein graft. We performed aortic valve replacement, mitral valve repair, and coronary artery bypass grafting with repeat sternotomy, moderate hypothermia (29.3°C), aortic cross-clamping, retrograde cardioplegia and proximal occlusion of the LITA graft using a soft bulldog clamp. The proximal LITA was occluded through a supraclavicular incision without intrathoracic dissection. Although cardiopulmonary bypass (CPB) time and aortic cross-clamp time were prolonged, the patient was taken off CPB without any problem. The postoperative course was uneventful. We believe that this technique is safe and effective for establishing myocardial protection without deep hypothermia and risk of LITA injury.

Questionnaire survey were conducted three times to evalute the social life and functional problems in patients with orthotopic neobladder after cystectomy. A total of 34 responses were collected froml9 patients with a mean age of 66 years at diagnosis. The patients with orthotopic neobladder were found to be troubled with prolonged urinary incontinence such as nocturnal enuresis and stress incontinence. The problems was deteriorating the quality of life of the patients.

A 44-year-old woman with Marfan's syndrome presented complaining of severe back pain. Angiography revealed annulo aortic ectasia, aortic regurgitation, acute aoric dissection (DeBakey IIIb) and distal aortic arch aneurysm. One month after admission, she underwent cardiopulmonary bypass was established through the femoral artery, the superior and inferior vena cava. The heart was arrested by aortic cross clamping and retrograde cold (20°C) cardioplegia. At first, a modified Bentall's procedure was done in addition to a Carrel patch procedure. After this procedure, the heart was perfused continuously (300ml/min) with warm (37°C) blood until the end of the cardiopulmonary bypass. The heart recovered a sinus rhythm spontaneously. Subsequently, aortic arch replacement and the elephant trunk method was done with the aid of deep hypothermia and circulatory arrest. The patients is well 1 year after the operation. This technique is useful for patients who require prolonged aortic cross clamping time.

Thalassemia is an inherited hemoglobin disorder characterized by hemolytic anemia. Reportedly, cardiopulmonary bypass (CPB) causes hemolysis; therefore, extreme caution is warranted during CPB. However, few studies have reported open heart surgery in patients with thalassemia. We report successful surgery for aortic stenosis and regurgitation (ASR) and an ascending aortic aneurysm (AsAA) in a patient with thalassemia. A 69-year-old woman was referred to our hospital for surgical management of ASR and AsAA. Comprehensive evaluation of microcytic anemia led to diagnosis of beta-thalassemia minor. We performed aortic valve and ascending aorta replacement; we used a biologic valve and performed open distal anastomosis under hypothermic circulatory arrest (25°) combined with retrograde cerebral perfusion. Non-pulsatile flow circulation was maintained using a centrifugal pump during CPB. The suction and ventilatory pressures were decreased, and we performed dilutional ultrafiltration. A spare artificial lung was connected to the CPB to avoid complications in the event of artificial lung blockage. We did not observe any hemolysis-induced adverse event during the clinical course, and the patient was discharged 20 days postoperatively. Careful preoperative evaluation is essential to confirm thalassemia before cardiovascular surgery to establish an optimal surgical strategy and avoid the risk of CPB-induced hemolysis in patients with the hematological disorder.

Ischemic mitral regurgitation (IMR) is a serious and increasingly common clinical disorder, but at present, the relationship between left ventricular shape and IMR is not completely understood. Thirty patients with moderate or severe IMR who underwent mitral valve surgery combined with coronary artery bypass grafting were studied retrospectively. Left ventricular shape, left ventricular regional wall motion, hemodynamic index, condition of the coronary artery, severity of IMR and long term results were assessed using ventriculography and angiography. Left ventricular shape at end diastole and end systole were quantified based upon the ratio of the major-to-minor axis and the sphericity index. Hospital mortality rate was 13.3%, 5 years survival rates were 10.5%, and 5-year rate of freedom from congestive heart failure (CHF) were 7.8%. Significant difference between cardiac deaths (n=11) and survivors (n=19) included requiring intensive care admission, requiring intra-aortic balloon pumping, recurrent myocardial infarction, the ratio of the major-minor axis at end diastole, the sphericity index at diastole, and the sphericity index at end systole. Multivariable regression analyses were performed with the Cox proportional hazards model. Significant determinants of survival were the sphericity index at end systole and LV regional wall motion at the site of the anterobasal segment or apex. These findings indicate that the shape of the LV and LV regional wall motion in IMR may be important determinants of prognosis and suggest that surgical attention to shape may be helpful for mitral valve surgery.

We report two cases the first was a 74-year-old woman who had received coronary artery bypass grafting [SVG-to-LAD, SVG-to-Cx, SVG-to-RCA, the left internal thoracic artery (LITA) was mobilized but was unsuitable for the graft] two years previously. Postoperative angiography revealed graft occlusion. Since repeated catheter intervention was not successful, reoperation was performed. A MIDCAB procedure with radial artery graft and proximal anastomosis was performed on the left axillary artery. The operation was successful and there were no complications. Two weeks after the operation, the graft patency was confirmed and she was discharged. The second case was a 64-year-old man who received coronary artery grafting (LITA-to-LAD, SVG-to-Cx and SVG-to-RCA). Two months after the operation, recurrent chest pain was caused by severe stenosis of the LITA anastomotic site. Percutaneous transluminal coronary angioplasty was performed but was unsuccessful. He received redo CABG in the same manner using the saphenous vein. The postoperative course was uneventful and he was discharged 6 days after the operation. This procedure is useful for the patients whose left internal thoracic artery has been used on a previous operation. Good early results were obtained in both patients.

A 62-year-old man was transferred to our institution with ventricular fibrillation. Percutaneous cardiopulmonary support (PCPS) was established and he underwent successful percutaneous transluminal coronary angioplasty. Since his left ventricular function did not recover, he was placed on a left ventricular assist system (LVAS). Under general anesthesia, a 10-cm longitudinal incision was made on the right parasternum. The third and fourth cartilages were completely resected. The pericardium was incised longitudinally. At first, an inflow cannula was insected to the right side of the left atrium. The ascending aorta was then partially excluded and an outflow cannula with a 10mm Gore-Tex prosthesis was anastomosed end-to-side to the aorta with a continuous Gore-Tex suture. After the pump was established, PCPS was gradually discontinued. During 9 days of support, his left ventricular function recovered and subsequently he was weaned from LVAS. Unfortunately, he died two days after LVAS removal. We think this procedure is useful because it is easy to perform, reduces the bleeding, shortens the operating time.

Syncope is a common chief complaint in emergency departments, and although causes in most patients with syncope are benign, some patients have a serious disease. Here we report a 50-year-old patient with facial trauma who had past history of alcoholic liver cirrhosis. He fell down by syncope due to portopulmonary hypertension (PPHTN) accompanied by portal hypertension. Oral ambrisentan, a potent ET_A-selective receptor, 2.5 mg once a day was initiated. His ECG and the results of cardiac catheterization showed improvement in hemodynamic abnormality after the treatment. Also, the patient had no significant symptoms, including syncope, for nine months after receiving ambrisentan.

Because the corona disaster made group medical training difficult, we conducted resuscitation training for new students and basic medical skills training for fourth-year students without face-to-face instruction using video learning, assessment, and ICT. In the resuscitation training, the students were allowed to take a mannequin home and film themselves performing the resuscitation while learning by video. Later, group and peer assessment were conducted via Zoom, and a significant increase in self-assessment was observed. In the basic medical skills training, the students filmed their own implementation at their own pace while learning by video, and the teachers later conducted video assessment and feedback. The lack of face-to-face instruction made it possible to implement the limb spine training, which had not been possible in previous years. It is necessary to adjust the timing of the video registration by the students and the video assessment by the teachers, and to make further improvements to the system.