It is the most important for young cardiovascular surgeon that ensure the number of cases to obtain and renew the specialties qualifications. Regional disparities such as concentration of facilities in urban areas and shortage of physicians in rural areas, may be affecting the lack of cases. I compared the population of each medical region with the number of cardiac surgery training facilities to examine regional disparities in cardiovascular surgery. As one way to solve the regional disparity problem, I make a suggestion to decentralize young doctors from urban areas to rural areas.

Many cardiovascular surgeons are well aware of the importance of non-technical skills but don't know what behaviors with high quality non-technical skills are in the operating room. The Non-Technical Skills for Surgeons (NOTSS) system was developed to be used as a debriefing tool for supervisors to assess the non-technical skills of trainee surgeons and provide feedback immediately after surgery. The NOTSS system has the four categories containing three elements respectively, with "good behavior" and "bad behavior" indicated for each element. The purpose of this column is to introduce the NOTSS and to provide an opportunity to think about how cardiovascular surgeons should behave in the operating room. Jpn. J. Cardiovasc. Surg. 53(3): U1-U4 (2024)

Prosthetic graft infection after arch replacement surgery is a serious complication that is often resistant to antibiotics. However, graft replacement is difficult and is very invasive. We performed anterior small thoracotomy drainage and intermittent lavage in 2 patients. First, the prosthetic graft was approached via a left third intercostal thoracotomy. After the ablation of infected tissues and cleansing with saline, drains were placed both proximally and distally to the vascular graft. An irrigation withdrawal drain was then implanted in the left thoracic cavity. After surgery, diluted povidone iodine solution, pyoktanin solution, and saline were used for pleural lavage. Case 1 : An 82-year-old man underwent arch replacement for a ruptured aortic arch aneurysm in November 2005. He suffered from high-grade fever from March 2008 and was referred to our hospital from another hospital with a diagnosis of vascular graft infection. A small anterior thoracotomy and drainage were performed on April 9. Pleural lavage with povidone iodine solution was performed 9 days after surgery, then was performed with saline from days 10-13 after surgery. The patient was discharged on postoperative day 30. Case 2 : A 58-year-old man complained of high-grade fever from March 16, 2009. He had undergone arch replacement for an aortic arch aneurysm in 1997. He consulted a physician and was referred to our hospital with a diagnosis of vascular graft infection. Methicillin-sensitive Staphylococcus aureus (MSSA) was identified by blood culture. A small anterior thoracotomy and drainage were performed on March 24. Immediately after surgery pleural lavage was performed with pyoktanin blue solution changing to povidone iodine on postoperative day 10. Pleural lavage was continued until day 34, and the patient was discharged on postoperative day 64. In both cases, drainage and pleural lavage with antibiotic solutions improved the patients' general condition. The infections have not recurred since discharge. Small anterior thoracotomy for graft infection after arch replacement, in addition to being minimally invasive, can avoid the need for a second median sternotomy, and can provide an adequate view of the full length of the arch prosthetic graft.

Mitral valve replacement (MVR) is an effective method to treat mitral valve regurgitation (MR) associated with hypertrophic obstructive cardiomyopathy (HOCM) because of systolic anterior movement (SAM) of anterior leaflet. We retrospectively investigated results of mitral valve surgery concomitant with septal myectomy for MR with HOCM. Between August 2008 to July 2009, 7 patients underwent septal myectomy. Among them, 6 patients who had moderate or severe MR preoperatively were objects of this study. Pre and post operative clinical conditions, findings of echocardiogram, and operative techniques employed in each patient were reviewed. Four patient successfully underwent mitral valve plasty (MVP) with septal myectomy. One patient needed only septal myectomy because MR subsequently disappeared with resolution of SAM. One patient resulted in MVR after attempted mitral valve plasty (MVP). SAM disappeared in all patients who had MVP, and residual MR was mild or less. Pressure gradient of left ventricular outflow significantly decreased in all cases. All patients discharged hospital uneventfully. Plication of posterior leaflet, anterior leaflet augmentation if necessary, and prudent use of annuloplasty ring seemed to be effective for successful MVP in HOCM patients. MVP is feasible even in patients with MR derived from HOCM.

Minimally invasive surgery is associated with a faster postoperative recovery because of reduced postoperative pain and improved respiratory function, especially in elderly patients. We began using a minimally invasive approach (small parasternal incision) for isolated aortic valve replacement (MICS AVR) from January 2011. Between January 2011 and February 2012, 32 patients underwent MICS AVR surgery. The mean age was 73 years (range 57-85 years) ; 69% were women. MICS AVR was performed through a skin incision of 6.5±0.5 cm along the third intercostal space. Cardiopulmonary bypass was established through the right femoral artery and vein. The patients were cooled to 28°C, the aorta was crossclamped with a flex clamp, and antegrade cardioplegic solution was given into the aortic root or selectively into the coronary ostia. The aortic valve procedure was performed in a standard fashion. If the distance to the aortic valve was too far, we used surgical instruments for minimally invasive surgery. Conversion to a conventional approach was not necessary in any patient. Mean overall operative time was 250±49 min, cardiopulmonary bypass 140±34 min, and crossclamp time 99±22 min. Mean ICU stay was 1.2±0.5 days and length of hospital stay was 10.3±2.2 days. There was no re-operation for bleeding or surgical site infection. MICS AVR was safe and feasible with excellent outcome. The advantages of this procedure include reduced bed rest, decreased postoperative pain, avoidance of deep sternal wound infection, and cosmetically attractive results. We now use the minimally invasive approach whenever possible. We report an early outcome, experience, strategy, and surgical technique.

Infra-renal abdominal aortic aneurysms were electively treated by bifurcated endovascular stent grafts (Power Web^TM system, Endologix Co., USA) at 5 Japanese centers. The stent grafting (SG) was applied for candidates nominated by the selection committee after informed consent was obtained according to the IRB in each center. The delivery success rate of 60 patients (53 males) was 96.7%. There were 2 patients with type I endoleaks, resulting in a technical success rate of 93.3%. The operation time of 193±55min and blood loss of 440±240g were significantly shorter and less, respectively in the SG group when compared with 303±88min and 1, 496±2, 025g in 97 patients (83 males) treated by conventional open surgery. Endoleaks were detected in 4 patients (type I: 3, type II: 1) by CT scan taken at the time of discharge or 1 month after SG procedure. Type I endoleak was observed in patients with short and severely angulated SG landing zones. Renal artery obstruction, and temporary buttock pain caused by internal iliac artery occlusion occurred, but there was no hospital death. In 56 patients excluding an SG-unrelated death and a dropout from surveillance, there was no secondary endoleak or marked adverse events at all except 1 SG limb occlusion during a 6-month follow up period. The aneurysm size shrank in 26 patients and remained unchanged in 30 patients. No aneurysm enlargement was observed. The Power Web^TM system is appropriate for minimally invasive surgery for abdominal aortic aneurysms. Long-term follow-up studies will follow.

Along with clinical practice and education, research is among the most important activities for medical doctors. The same is true in cardiovascular surgery: Young cardiovascular surgeons are expected to improve their surgical techniques and prioritize their clinical practice. However, their perspective on the role of research in their field of expertise is unknown. Therefore, we conducted a survey of and discussion with young cardiovascular surgeons to clarify their thoughts and concerns about performing research. Here we review and report the survey and discussion results.