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.

This paper reports on a case in which a heavily-calcified so-called “porcelain aorta” (including the ductus arteriosus) was observed, together with a patent ductus arteriosus and aortic stenosis associated with a bicuspid aortic valve. A 76-year-old man had been referred to our hospital on a diagnosis of aortic stenosis. Since angiography revealed slight contrast in an area on the right side of the heart, echocardiography was performed and revealed patent ductus arteriosus. Severe circumferential calcification of the ascending aorta and aortic arch was observed on CT scans. Almost no calcification was observed in other areas. Aortic valve replacement and closure of the ductus arteriosus (transpulmonary approach) were performed by means of a balloon to temporarily occlude the aorta, as surgical clamping was impossible due to calcification. Hypothermic systemic perfusion and antegrade selective cerebral perfusion were used. The postoperative progress of the patient was good. Bicuspid aortic valve and patent ductus arteriosus are highly likely to be present in combination in cases of congenital cardiac anomaly, and it is therefore necessary to be particularly attentive when diagnosing such cases. It was considered that our patient, an adult suffering patent ductus arteriosus, was a rare case in which the calcified ductus arteriosus was observed and the calcification had spread to the ascending aorta.

In cases of stent-grafting for ruptured aneurysm, endoleak is a serious problem. We report 2 cases of ruptured aneurysms that were treated with endovascular stent-graft placement. Case 1: A 79-year-old woman had a ruptured thoracic aortic aneurysm that was treated with endovascular stent-grafting from the distal arch to the descending aorta. Although her infra-operative course was uneventful, she died suddenly the day after operation. Autopsy revealed re-rupture of the aneurysm due to endoleak from the proximal site. Case 2: An 84-year-old woman was treated with endovascular stent-grafting for ruptured abdominal aortic aneurysm. The stent-graft was inserted from the infra-renal abdominal aorta to the right common iliac artery with femoro-femoral crossover bypass placement. There was evidence of type II endoleak that occurred via the left internal iliac artery (IIA) and inferior mesenteric artery (IMA) 16 days after surgery. A CT scan performed 6 months after surgery revealed an increase in aneurysm size and persistent type II endoleak. Both embolization of the aneurysmal sac through the IMA and surgical ligation of the IMA failed, and endoleak from the IMA persisted. Re-rupture of the aneurysm occurred 10 months after initial surgery and emergency open surgery was performed. In stent-grafting for ruptured aneurysms, only the thrombus outside the graft resists the pressure caused by the endoleak. We conclude that endoleak after stent-grafting for ruptured aneurysm should be treated completely as soon as possible because of the risk of re-rupture.

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.

We performed endovascular stent-graft placement on 39 patients with abdominal aortic aneurysms between 1996 and March 2002-a period of approximately 5 years (first half: until the end of June 1998, second half: July 1998 onward). Three patients in the first half of the period and 8 patients in the second half were 80 years or older. Two cases of mycotic aneurysm were observed. During the second half, we encountered high-risk cases in which the patients had complications such as coronary artery disease (5 patients), COPD (1 patient) and thoracic aortic aneurysm (4 patients). Although we had to switch to surgery in 3 patients during the first half of the period, we successfully placed stent-grafts in the other 36 cases (92%). Endoleaks were observed in 6 patients, and dissection of the iliac artery was observed in 5 patients (stents had been placed in all patients). In 50% of all cases in the first half of the period and 89% of all cases in the second half, stent-graft placement was successful and no endoleak was observed. During the follow-up period, 3 cases required additional treatment, and another 4 cases required surgery. Four patients died in hospital during the first half of the period, and 3 patients died during the following 3 years. The 3-year survival rate was 82%. It was considered that stent-graft placement for abdominal aortic aneurysms is particularly effective for high-risk patients, and that the results of this type of therapy will improve in the future.

We focused on the traditional processing method which generates the superior quality of Yamato-shakuyaku. First, we assessed the historical literature written around Edo and Meiji period and rediscovered the traditional air drying method still inherited in Nara Prefecture. Then, we gathered and analyzed the data of medicinal plants production in Nara Prefecture among 1938 and 2019, and investigated the decline of local production and experienced agricultural techniques of peony through the transition of its yield. In order to visualize the ancient knowledge of crude drug manufacturers that contributes to the instruction of the skills for supply of seedlings, cultivation, and processing, we settled the meteorological observation devise at the outdoor drying shelf for 3 years, and recorded the real drying environment. When comparing the meteorological data with other cultivating area of peony using the estimated values of Agro-Meteorological Grid Square Data, the climate of Nara Prefecture was with high temperature and low humidity than other areas, and it seems to be quite suitable for air drying with adequate topography. The wind rose calculated by measured values of wind direction and wind speed showed the wind conditions in Nara that west wind was frequent in daytime and wind conditions are mildly but diversely changing. Among other producing areas of peony, the mechanical drying is major, whereas air-drying with low cost utilizing local environment features is still applied in Nara. We revealed the rationality of traditional methodology by digitization of meteorological factors which can be high added value.

Panax notoginseng is a commonly used traditional Chinese medicine with blood activating effect while has continuous cropping obstacle problem in planting process. In present study, a semimicroextraction method with water-saturated n-butanol on 0.1 g notoginseng sample was established with good repeatability (RSD<2.5%) and 9.6%-20.6% higher extraction efficiency of seven saponins than the conventional method. A total of 16 characteristic peaks were identified by LC-MS-IT-TOF, including eight 20(S)-protopanaxatriol (PPT) type saponins and eight 20(S)-protopanaxadiol (PPD) type saponins. The established method was utilized to evaluate the quality of notoginseng samples cultivated by manual intervened methods to overcome continuous cropping obstacles.As a result, HPLC fingerprint similarity, content of Fa and ratio of notoginsenoside K and notoginsenoside Fa (N-K/Fa) were found out to be as valuatable markers of the quality of samples in continuous cropping obstacle research, of which N-K/Fa could also be applied to the analysis of notoginseng samples with different growth years.Notoginseng samples with continuous cropping obstacle had HPLC fingerprint similarity lower than 0.87, in consistent with normal sample, and had significant lower content of notoginsenoside Fa and significant higher N-K/Fa (2.35-4.74) than normal group (0.45-1.33). All samples in the first group with manual intervention showed high similarity with normal group (>0.87), similar content of common peaks and N-K/Fa (0.42-2.06). The content of notoginsenoside K in the second group with manual intervention was higher than normal group. All samples except two displayed similarity higher than 0.87 and possessed content of 16 saponins close to normal group. The result showed that notoginseng samples with continuous cropping obstacle had lower quality than normal sample. And manual intervened methods could improve their quality in different levels.The method established in this study was simple, fast and accurate, and the markers may provide new guides for quality control in continuous cropping obstacle research of notoginseng.