We report a 78-year-old man who had an impending ruptured atherosclerotic arch aneurysm combined with chronic dissecting ascending aortic aneurysm. The patient underwent a graft replacement of the ascending aorta and aortic arch using the elephant trunk method with the aid of profound hypothermia and continuous retrograde cerebral perfusion. Cerebral blood velocity was measured with transcranial Doppler (TCD) during operation. The TCD flow pattern after weaning of cardiopulmonary bypass indicated a state of brain edema. Therefore it is important in extensive retrograde cerebral perfusion to control the perfusion pressure and prevent destruction of the blood brain barrier aggressively. Pharmacological intervention could improve the safety of retrograde cerebral perfusion. Postoperative diagnostic images showed that the part of the distal anastomosis around the elephant trunk was not surrounded with thrombus. At this stage, it is not necessary to perform next extensive aortic replacement. It is important to consider the occurrence of complication, who using elephant trunk method, including paraplegia, thromboembolism, kinking of prothesis.

Aortic dissection during cardiac operation is a rare but serious complication. Early detection and adequate repair is essential in this situation. A 69-year-old man in whom an aortic valve sparing operation for aortic root dilatation with aortic regurgitation had been begun, had an intraoperative aortic dissection 10min after the start of right axillary artery perfusion. Intraoperative transesophageal echocardiography and direct epi-aortic echo revealed acute aortic dissection extending from the aortic root to at least the descending aorta. The dissection was successfully repaired by a Bentall operation and hemiarch replacement using hypothermic circulatory arrest, selective cerebral perfusion, and antegrade perfusion from an anastomosed graft.

A 75-year-old man with underlying arteriosclerosis obliterans presented with acute heart failure secondary to rest pain of the right lower extremity. Echocardiogram showed severe mitral regurgitation, moderate tricuspid regurgitation and a low cardiac function (ejection fraction : 27%). Right toe gangrene developed in association with continuous acute heart failure. He underwent mitral valve replacement, tricuspid annuloplasty, right common femoral artery-posterior tibial artery bypass and amputation of the right toes in single-stage surgery. There were no major complications during his hospital stay. After surgery, his symptoms significantly improved.

We report the rare case of a 68-year-old man, who was admitted to our hospital with a diagnosis of aortic arch anastomotic pseudoaneurysm, with concomintant aortic root enlargement and coronary artery stenosis. Eleven years previously, at age 56, he underwent total arch replacement with island reconstruction for chronic aortic dissection. We performed redo total arch replacement, aortic root replacement and coronary artery bypass, making use of a cardiopulmonary bypass with cannulation through the right subclavian artery, femoral artery and femoral vein before resternotomy. We also used selective cerebral perfusion. Postoperatively, the patient temporarily required reintubation ; however, he was discharged in good condition on the 50th post-operative day. The case suggests that island reconstruction has the potential to cause an aortic arch pseudoaneurysm, particularly after a long postoperative period of time. Therefore, thorough postoperative care strategy is required. We also need to consider surgical reconstructive techniques which eliminate vascular lesions as much as possible at the time of the primary surgery, particularly in cases of chronic aortic dissection.

Objective : Transarterial or transapical aortic valve replacement (TAVR) procedures have been performed for high-risk patients with severe aortic valve stenosis (AS) in western countries. A high-risk patient is defined as having an STS score greater than 10%. In Japan, aortic valve replacement (AVR) with cardiopulmonary bypass (CPB) is standard care for AS, even if the patient is at high risk of developing complications. We calculated an expected operative risk of patients using a JAPAN score established by Japanese Adult Cardiovascular Surgery Database (JACVSD). Patients and Methods : Patients were divided into three groups : score less than 5%, low risk (LR) ; score 5-10%, moderate risk (MR) ; score more than 10%, high risk (HR). We also evaluated the efficacy of conventional AVR in each group. Between January 2002 and May 2011, we performed conventional AVR in our hospital and 116 patients who underwent AVR for symptomatic AS were enrolled in this study. Results : There were 79 patients in the LR group, 30 patients in the MR group and 7 patients in the HR group. The mean score was 2.6±1.1% in the LR group, 6.8±1.4% in the MR group and 23.3±16.8% in the HR group respectively. The mean follow-up period was 7.6±0.3 years. Preoperative co-morbidity was not statistically significant among three groups, however more octogenarians were found in the HR group. The aortic valve area and left ventricular ejection fraction (LVEF) were significantly smaller in the HR group. There were 4 cancer patients. The HR group had significantly longer operation and CPB times than the LR group. The operative mortality in all cases was 1.6%. Overall survival at 5 years was 78%. Actual survival at 5 years was 77% in the LR group, 82% in the MR group and 71% in the HR group. The major adverse cardiac and cerebrovascular event (MACCE)-free ratio at 5 years was 85%. Absence of death caused by MACCE at 5 years was 93%. All cancer patients died after AVR due to advancement in cancer. Conclusion : The results of conventional AVR with CPB were satisfactory in each group. Cancer patients may be good candidates for TAVR in the future.

We report 2 cases of successful treatment by percutaneous catheter drainage and irrigation for methycillin-resistant Staphylococcus aureus (MRSA) prosthetic graft infection after abdominal aortic aneurysm (AAA) repair. Case 1 was a 71-year-old man in whom MRSA graft infection was diagnosed on the basis of high fever and CT-guided taps of the perigraft fluid 11 days after AAA repair, and a percutaneous catheter was inserted into the perigraft space by the CT-guided method. Case 2 was a 77-year-old man in whom MRSA graft infection was diagnosed because of high fever and purulent discharge from the wound of retroperitoneal drainage 5 days after AAA repair. A percutaneous catheter was placed into the retroperitoneal space via an extraperitoneal route. In both cases, intermittent irrigation by 0.5% Povidone-iodine solution and saline was performed as well as systemic and local antibiotic administration. The graft infection was well controlled and both patients were discharged after 4 months. Percutaneous catheter drainage and irrigation can be one of the choices for critically ill patients with graft infection after AAA repair.

The shortage of physicians in Japan has been a social issue since the new postgraduate clinical training system started in 2004.The difficult working conditions of hospital physicians may influence this problem.We used a questionnaire to investigate the working hours, on-call frequency, work contents, and mental health of supervisors at various residency training hospitals in Japan.
1) We surveyed 479 physicians who worked at hospitals certified as residency-training facilities and who participated in a development workshop for supervisors or for residency training program managers held at 8 locations in 2004.
2) We found that supervisors worked, on average, more than 100 hours longer than statutory working hours per month and that more than one-fifth of supervisors worked more than 160 hours longer.
3) As for mental health, more than one-fifth of supervisors showed a depressive tendency.
4) These results suggest that the working conditions of supervisors at residency-training hospitals in Japan should be improved by reducing their clinical duties or managing their work content.

The new postgraduate clinical training system that started in 2004 is expected to have positive effects on the health of residents and the quality of treatment they provide.We performed a survey to examine the effects of this training system on the mental health of residents.
1) The subjects were first-year residents (458 in 2003 and 549 in 2004) who had started postgraduate clinical training at 38 hospitals in Japan.Self-administered questionnaires, which included items about working conditions and mental health, were mailed to each subject.
2) The mean score on the 12-item version of the General Health Questionnaire was 4.8 both before and after the new training system was introduced.The mean Center for Epidemiologic Studies Depression Scale score was 15.3 before and 14.4 after the system's introduction.The results showed no significant difference in mental health of residents before and after the system was changed.
3) The results suggest that the new training system has a positive effect on residents' mental health by increasing sleep time and decreasing occupational stress; however, the new system has also decreased job satisfaction and negatively affected their mental health.
4) Job satisfaction may significantly affect the mental health of residents.

Physical performance measures, such as gait speed, one-legged stance and hand-grip strength, are known as assessment measures of motor function and predictors for adverse health outcomes, and widely used for assessing motor function in preventive programs for long-term care or screening of frail elderly. However, there is no standard assessment sheet for feedback of the results. In the present study, an assessment sheet on physical performance measures for community-dwelling older adults was developed. A pooled analysis of data from six cohort studies, including urban and rural areas was conducted as part of the Tokyo Metropolitan Institute of Gerontology Longitudinal Interdisciplinary Study on Aging. The pooled analysis included cross-sectional data from 4683 nondisabled, community-dwelling adults aged 65 years or older. Quintiles were derived according to age and sex group for six physical performance measures, i.e., hand-grip strength, one-legged stance, and gait speed and step length at both usual and maximum paces. The assessment sheets, which indicated the physical performance level according to age and sex, were developed by fitting third order polynomial curves to the data. The reference values in the present assessment sheet were considered to be derived from better represented community-dwelling older adults by using more large-scale population-based cohort data than that in the previous study. The assessment sheet should be useful for feeding back results on physical performance measures to elderly individuals and help them better understand their own physical performance levels.

An aortoesophageal fistula is a critical condition with high operative mortality. A case of aortoesophageal fistula following thoracic endovascular aneurysm repair is reported. The patient was a 72-year-old man complaining of dysphagia who underwent stent grafting for a saccular aneurysm of the descending aorta that was compressing the esophagus four months earlier. Endoscopic examination showed perforation of the aneurysm into the esophagus with severe stenosis. The aneurysmal sac was filled with thrombus. Aortography demonstrated a type I endoleak from the lesser curvature of the aortic arch, draining into the aneurysmal sac. The patient was afebrile with moderate elevation of C-reactive protein, and the white blood cell count was normal. The patient underwent closure of the aneurysmal entry with healthy aortic wall and replacement of the descending aortic aneurysm with a prosthetic graft. The graft was isolated from the fistula by an omental flap. The patient's postoperative course was uneventful. Computed tomography performed 4 years after the surgery showed shrinkage of the aneurysmal sac. The patient has had a healthy life for 9 years since the operation.