Background : Perioperative care in congenital heart surgery has evolved in recent years, and it was considered a contributive factor to improve surgical outcome and prognosis. Objective : To extract perioperative clinical protocols that have been applied in our hospital, then assess their usefulness for better clinical outcome. Methods : We retrospectively reviewed our patients' records to analyze representative perioperative protocols that might have contributed to surgical outcome, such as intraoperative transesophageal echocardiography (ITEE), extubation in the operating room on patients of atrial septal defect (ASD), ventricular septal defect (VSD), tetralogy of Fallot (TOF), Glenn procedure and Fontan procedure. We also assessed clinical pathway of ASD and VSD, and each protocol was individually explored to calculate achievement ratio in order to show its adequacy. Results : This study included 482 of on-pump surgery patients and 146 of off-pump surgery patients from June 2007 to June 2014. ITEE was performed in 474 of on-pump surgery patients and 102 of off-pump surgery patients. No case had a residual lesion immediately after operation. Extubation in the operating room was performed in cases without severe pulmonary hypertension (PH). The extubation ratio was 94.7% (ASD repair), 60.0% (VSD repair), 50.0% (TOF repair), 42.5% (Glenn procedure), and 45.2% (Fontan procedure), respectively. Clinical pathways of ASD and VSD included patients without severe PH. Achievement ratio of the clinical pathway was 98.2% in ASD and 94.2% in VSD patients, respectively. Four patients were excluded because of high c-reactive protein (CRP), and one patient because of familial circumstance. Conclusion : ITEE was useful in evaluation of cardiac function, residual issue and residual air at weaning of cardiopulmonary bypass. Reintubation did not occur in any clinical course of extubation in the operating room, but the extubation rate was not high because of safety concerns. Achievement ratio of the clinical pathways of both ASD and VSD was more than 90%, therefore, application of the clinical pathway was considered appropriate.

  Since 2010 we have held morbidity and mortality conferences established on the basis of the needs of residents in the postgraduate training program of Nagano Red Cross Hospital. In addition to teaching about patient safety, we consider the palliating “second victim” effect. Senior residents act as moderators and will gain valuable experience as conference facilitators. Here, we report on the conference because we believe its background is unique. For further improvement, the educational effects of the conference should be analyzed.

Upper ministernotomy is frequently selected in aortic valve replacement by minimary invasive cardiac surgery. However, retrograde cardioplegia cannulae cannot be inserted to some sites. CT examinations in our department revealed that lower ministernotomy can be used for surgery of the aortic valve in many Japanese cases. The usefulness of 2 approaches was examined in 68 cases with aortic valve disease who received aortic valve replacement by minimary invasive cardiac surgery from January 1997 to March 2002: Those who received upper ministernotomy (U group) and those who received lower ministernotomy (L group). Retrograde cardioplegia is frequently used in aortic valve replacement for myocardial protection. Those in the L group showed effectiveness in myocardial protection and in securing the operation field except in cases who were switched to full sternotomy. In the L group, the MAZE operation was performed and no significant differences were observed in aortic cross-clamping time, artificial cardiorespiratory time, operation time, bleeding amount and other factors. Lower ministernotomy was more effective than upper ministernotomy in myocardial protection by retrograde cardioplegia and securing the operation field in aortic valve replacement by minimally invasive cardiac surgery.

We encountered 15 cases of surgical site infection (SSI) by Methicillin-resistant Staphylococcus aureus (MRSA) among 153 patients who underwent a cardiovascular operation in 2000. SSIs consisted of 5 mediastinal infections, 9 surface wound infections and 1 artificial graft infection after an abdominal aortic surgery. All infected cases had been operated on between June and December 2000. Eighty-three cases, which underwent cardiovascular operations during this period, were divided into SSI or no-SSI groups and their clinical data were analyzed. The data included age, gender, preoperative diabetes, urgency, preoperative usage of a device like Swan-Ganz catheter or IABP, preoperative albumin level, preoperative physical state by ASA score, National Nosocominal Infections Surveillance index, duration of operation, usage of a cardiopulmonary bypass, duration of bypass, type of operation, and number of distal anastomoses in CABG operations. Multivariate analysis showed gender (male), diabetes, and emergency operation as independent risk factors for the incidence of SSI by MRSA. One patient, who suffered a mediastinal infection after CABG, had confirmed as demonstrating the colonization of MRSA in sputum preoperatively. Microbiological screening of medical staff showed 2 of the 6 surgical doctors and 3 of the 25 ward nurses exhibited colonization with MRSA. DNA analysis of MRSA, harvested from 5 infected patients, indicated at least 2 strains of MRSA and 1 of the 2 strains was identical to the MRSA that was detected in a doctor. We applied prophylactic measures with reference to the guideline for prevention of surgical site infection announced by CDC in 1999, which included the following: routine work-up of MRSA-colonization, and treatment of all MRSA colonized patients and those undergoing emergency operations with Mupirocin. Preoperative patients were isolated from MRSA-infected or colonized patients. MRSA-colonized surgical personnel were treated with Mupirocin ointment. Cephazoline was administered shortly before and after the operation as a prophylactic antibiotic. Vancomycin was added to Cephazoline in patients with a history of MRSA-colonization or infection. Through hand washing before and after daily contact with patients was emphasised to all medical staff. SSI surveillance conducted by an infection control team was implemented. After the introduction of the prophylactic measurements, one MRSA-SSI was observed among 113 cases who underwent a cardiovascular operation between January and September 2001.

Minimally invasive cardiac surgery (MICS) for treating valvular disease was introduced in our division in July 1997, and we have treated a total of 236 cases by July 2002. Among the various types of surgical treatment, there were 21 cases (M-group) of double valve replacement (DVR) to treat combined valvular disease. There had been 8 cases (F-group) of DVR by means of conventional full sternotomy during the period from January 1990 to June 1997, before the introduction of MICS. A comparison of the results of these surgical treatments yielded the following results. There were no differences in operation time and blood loss during the operations between the 2 groups, whereas the aortic cross clamp time and cardiopulmonary bypass time were significantly longer in the M-group than the F-group (M-group: 189±6 and 228±7min; F-group: 132±18 and 183±16min, respectively). There were significantly more cases of concomitant maze operation in the M-group than in the F-group. There were no differences in the durations of postoperative intubation or ICU stay. The days required from operation to starting walking were significantly shorter in the M-group compared to in the F-group (M-group: 2.4±0.2 days; F-group: 3.3±0.2 days), while there were no differences in the postoperative hospitalization periods. There were no major postoperative complications, and 1 case each there was 1 death in each group during the hospitalization period. Although the aortic cross clamp time and cardiopulmonary bypass time were longer in the M-group than in the F-group, the postoperative course and surgical outcome were good. So MICS for DVR was considered acceptable. In addition, MICS was thought to provide high patient satisfaction with regard to cosmesis or thoracic fixation, although early discharge from the hospital, which was possible in cases of single valve MICS, was not obtained.