We performed transatrial repair of postinfarction posterior ventricular septal defect (VSP) in a 69-year-old man who was transferred to our hospital with a diagnosis of posterior acute myocardial infarction and VSP. Coronary angiogram revealed total occlusion of the right coronary artery at #3 and 75% stenosis of the left circumflex artery at #13. UCG revealed the ventricular septal defect on the posterior ventricular septum without LV wall motion abnormality. Surgical repair was planned around 3-4 weeks later because his hemodynamic state was stable without inotropes nor IABP support upon arrival. Under general anesthesia, standard median sternotomy was performed and cardiopulmonary bypass was established with the ascending aorta and bicaval cannulation. Cardiac arrest was achieved with antegrade cold crystalloid cardioplegic solution and an oblique right atrial incision was made. The VSP was visualized via the tricuspid valve. The location of VSP was confirmed with saline injection from the LA vent line. VSP was closed with two patches, consist of a Teflon felt and a bovine pericardial patch, from the left and right ventricle side with six 4-0 polypropylene mattress sutures. Also coronary artery bypass for LCx was performed with a saphenous vein graft. The postoperative course was uneventful. There was no residual ventricular septal shunt and LV function was normal by UCG. Right atrial approach for surgical repair seemed to be useful for posterior VSP.

Absent pulmonary valve (APV) syndrome is a rare anomaly that is usually associated with tetralogy of Fallot (TOF) and causes severe respiratory distress by compression of the trachea. Mortality following surgical repair in these patients is increased, especially in infants presenting with severe respiratory compromise. Preoperative ventilator dependency and age at operation are risk factors for mortality after surgical repair. Between 1995 and 1999, 5 patients underwent surgical treatment for TOF with APV. The mean age at operation was 9 months (range: 1 to 29 months), and the mean weight at operation was 5.2kg (3.6-9.1kg). Among these patients, 3 patients presented with severe respiratory distress caused by dilatation of aneurysmal pulmonary artery (pulmonary artery index>2,000) and 2 of these patients were dependent on a respirator prior to surgical treatment. Reduction of dilated pulmonary artery, including anterior wall resection and posterior placation, was performed in all patients. In the patients with severe preoperative respiratory compromise, the right ventricular outflow tract was reconstructed with an extracardiac conduit with autologous pericardial valve leaflets to avoid pulmonary valve regurgitation after the operation and a transannular patch with a PTFE valve was used in 2 patients without respiratory compromise. One patient died suddenly 7 months after surgical intervention. Three of the surviving patients underwent a second right ventricular outflow tract reconstruction because of progressive right ventricular outflow tract stenosis. In two of these patients the right ventricular outflow tract was reconstructed with an extracardiac conduit with autologous pericardial valve leaflets at first operation. All surviving patients are well without any physical limitations and have been placed in NYHA class I. Despite the need for reoperation for right ventricular outflow tract stenosis, aggressive surgical treatment for TOF with APV has produced a satisfactory mid-term outcome.

We performed a double switch operation for the patients with corrected congenital transposition of the great arteries concomitant with intra-cardiac abnormalities including dextrocardia, non-confluent pulmonary artery and Ebstein's malformation between April 2003 and August 2006. The mean age and weight at the time of surgery were 38 months (range 2-89 months) and 10.7kg (range 4.6-16.1kg), respectively. Before the double switch operation, one patient had received a right modified BT shunt as a neonate and another had received bilateral modified BT shunts at the age of one month and 2 months respectively, followed by a central pulmonary artery angioplasty with installation of a right ventricle to a pulmonary artery shunt at the age of 5 years. For definitive repair, the Senning+Rastelli procedure was performed in two patients and Senning+Jatene procedure was performed in one patient. Mitral valve-and tricuspid valve plasties were performed, the atrialized right ventricle was plicated in the patient with Ebstein's malformation during the double switch operation. A Senning procedure was performed in patients with apicocaval juxtapositions. We reconstructed the systemic venous chamber with a dog-ear-like structure made from suture line pouches at the site of upper and lower portions of the atrial free wall, and the pulmonary venous chamber was completed, without augmentation with additional material. The mean surgery, cardiopulmonary bypass-and aortic cross clamp times were 606, 318 and 151 min, respectively. Postoperative CT scans showed smooth systemic venous returns and no pulmonary vein obstruction. No arrhythmias of any kind were detected after the double switch operation. These results suggest the suture line pouch technique in the atrial switch operation is useful in the double switch operation.

Objective : The ascending aortic cannulation (Ao-C) is the routine procedure for cardiopulmonary bypass (CPB) in our hospital. However, for patients with diseased ascending aorta, such as severely calcified aorta, dissected or aneurysmal aorta, we used brachiocephalic artery (BCA) cannulation. The effectiveness and simplicity of BCA cannulation was evaluated. Methods : For patients with diseased ascending aorta, BCA was cannulated when the diameter of BCA is larger than 10 mm and is free from calcification, since January 2013. There were 62 patients who underwent aortic valve replacement (AVR) for aortic valve stenosis and BCA cannulation was applied for 11 patients. Standard Ao-C was used for remaining 51 patients. There were 44 patients with dissected or aneurysmal ascending aorta and BCA cannulation was applied for 7 patients, axillary artery perfusion was used for 15 patients and standard Ao-C was used for 22 patients. Consciousness level at the time of awaking from general anesthesia and any complication related with BCA cannulation was evaluated for the effectiveness. Simplicity was evaluated by the time required to establish CPB after skin incision. Results : In AVR patients, there was 1 patient with delayed consciousness level recovery with BCA cannulation and this patient was found to have cerebral infarction by CT. Intraoperative aortic dissection, probably due to BCA cannulation was observed in 1 patient, very old fragile and long period steroid user. In diseased ascending aorta patients, no patient suffered neurological accident nor any complication due to cannulation. In AVR patients, the time required to establish CPB after skin incision was 51+/-9 min in BCA cannulation and 47+/-10 min in Ao-C patients (p=0.34). In diseased ascending aorta patients, the time required to establish CPB after skin incision was 49+/-49 min in BCA cannulation and 51+/-16 min (p=0.82). Conclusion : BCA cannulation is a very simple and safe technique to establish CPB for patients with diseased ascending aorta. However great care should be taken, and BCA cannulation should be avoided for the long term steroid users or patients with connective tissue disease.

In April, 1995, 392 teaching hospitals were surveyed by questionnaire regarding status quo of general medicine in Japan. Independent department of general medicine was established in 11 university and 16 non-university teaching hospitals (11.6% of the respondents). There were another 23 hospitals-3 universtiy and 20 non-university hospitals-in which general medicine was practiced at other department. Therefore, 50 hospitals (21.5% of the respondents) had a group of physicians practicing general medicine in one way or another.
Many problems surrounding general medicine, however, were raised, especially about conceptual gaps between generalist physicians and specialists or patients. It is mandatory for clinicians and educators in general medicine to make the concept of general medicine explicit in understandable words for other specialists and lay people. In addition, high quality practice, education and research products are essential to attract more doctors of younger generation.

At Tokyo Women's Medical University, our curriculum for first-year students is designed to teach the dynamics and etiquette of human relations. During the third year, medical students are expected to anticipate and plan effective therapeutic communication and interaction with patients. A discussion group of 6 students and a member of the human-relations committee first clarify the purpose and develop the training; students then independently participate in human-relations training during the summer vacation. After training, experiences are discussed during class. Although this curriculum has been used for some 10 years, its benefits have been assumed but not validated. We used student reports and questionnaires to examine the effects of this curriculum. The results clearly show that planning and training give the students an opportunity to learn how to establish an effective physician-patient relationship.

The committee of continuing medical education in Japan Society for Medical Education discussed on PRA of American Medical Association [AMA]. We have first analyzed the brochure of PRA for the members of AMA, and then prepared the questionnaire for AMA. We were able to obtained the answers to the questionnaire which were sent to AMA through courtesy of Japanese Medical Association (JMA). It was realized that AMA emphasizes an importance of PRA for medical practice to the patients; nevertheless acquisition rate of PRA is actually low, and so AMA proceeds with efforts towards completion of PRA.

The aim of this study is to clarify the present situation of activities of continuing medical education (CME) for the primary care physicians to whom the leading hospitals, such as universities and clinical trainee hospitals perform CME in their regions. A questionaire was designed for main 4 parts, as following: 1) On the purpose of CME for the physicians. 2) On the organization (office) managing CME in the hospitals. 3) On the strategies of CME. 4) On the evaluation of CME. Answers to a questionaire were replied from 234 institutions (58.1%). Analyzing the results, we recognized that the leading hospitals actively carried out CME for the primary care physicians in the community. Furthermore, conversion to experiential learning from passive learning and establishment of evaluation methods should be promoted in CME.

Because new media have come onstage in the information technology period, also self-learning methods have been diversified. Recently, small group discussion such as clinical conference using the mailing list is lively performed among the primary care physicians, and it is considered to be useful for continuing medical education. To promote the mailing list for continuing medical education, we present as follows; 1) present situation: to show a good example of TFC-ML (total family care-mailing list), 2) usefulness: to know new medical knowledge, new medical information and literatures etc., to discuss clinical cases. 3) issues: a role of moderator, excess of information, correspondence with slander, 4) future: to reevaluate usefulness for continuing medical education. We would like to expect effectiveness of mailing list for continuing medical education.

Background : Post-operative fluid management after cardiac valvular surgery is very important. In our institute, carperitide 0.0125 γ was started during surgery and oral furosemide 20-40 mg/day and spironolactone 25 mg/day were started at post-operative day (POD) 1 as the standard therapy. Tolvaptan, vasopressin V2 receptor antagonist, was started when fluid retention such as pleural effusion occurred. With this strategy, the frequency of pleural drainage was more than 40%. Therefore we changed our standard therapy in February 2018. In this new standard therapy, carperitide (0.0125 γ) was started and maintained until oral intake became possible and tolvaptan 7.5 mg was started with furosemide 20 mg and spironolactone 25 mg as oral medicine usually at POD 1. In this study, whether tolvaptan prevents pleural effusion or not after cardiac surgery was examined. Subjects and Methods : Sixty-four patients were operated during February 2017 and December 2018 were included in this study. Thirty-two patients operated in the period until January 2018 served as control group and were compared with 32 patients for whom tolvaptan was started on POD 1 (tolvaptan group). Results : There was no significant difference between two groups for background, operative procedure, operation time, cardiopulmonary bypass time, aortic cross clamp time and fluid balance during procedure. Tolvaptan was given to all patients in the tolvaptan group and in 22% of patients in the control group. Oral furosemide dose (tolvaptan group 21±5 mg/day, control group 31±20 mg/day, p＝0.0112), and the frequency of patients with intravenous furosemide administration (tolvaptan group 9%, control group 44%, p＝0.0038) were significantly less in tolvaptan group. In the tolvaptan group, intravenous furosemide administrated only once in all patients, whereas the frequency of intravenous furosemide administration was 1-32 times, average 6.6 times in control group. Tolvaptan was stopped within 1 week because of too much urination in two patients and the elevation of liver enzyme in two patients without any adverse effects. Post-operative urination volume until POD 5 did not differ. In both groups, body weight increased at POD 1 and 2 and returned to pre-operative weight at POD 3. Pleural effusion was significantly less in the tolvaptan group at POD 3 (tolvaptan group : none 66%, small amount 22%, moderate amount 3%, drain tube inserted 9%, control group : none 16%, small amount 34%, moderate amount 13%, drain tube inserted 38%, p＝0.0003), at POD 7 (tolvaptan group : none 72%, small amount 28%, vs., control group : none 47%, small amount 19%, moderate amount 22%, drain tube inserted 13%, p＝0.0041) and at discharge (tolvaptan group : none 94%, small amount 6%, vs., control group : none 69%, small amount 22%, moderate amount 9%, p＝0.0301). The frequency of pleural drainage was also less in the tolvaptan group (tolvaptan group 9.4%, control group 44%, p＝0.0038). Conclusion : After cardiac valvular surgery, tolvaptan started at POD 1 is very effective to reduce the frequency of pleural effusion and pleural drainage, and careful checking for too much urination and the elevation of liver enzymes is mandatory.