Minimally invasive aortic valve replacement (MIAVR) through right antero-lateral thoracotomy (ALT) has several advantages over traditional anterior chest approaches (right anterior thoracotomy, or partial sternotomy). First, ALT is less affected by anatomical variation of the position of the ascending aorta, second, concomitant mitral valve surgery is possible, and third, outcome in cosmesis is better. MIAVR can be done under direct vision and endoscopic assist. Longitudinal axillary incision and thoracotomy through the third inter-costal space is appropriate to directly look down the aortic valve. Endoscopic assist and tying down the sutures using a knot-pusher are mandatory. MIAVR can also be done totally endoscopically. Three dimensional endoscope and independent working ports for the right and left hand are helpful. Appropriate working space for the endoscopic surgery is obtained by antero-lateral approach. Standard valve can be used in endoscopic AVR, without using fastener devices.

We have performed trans-axillary aortic valve replacement (TAX AVR) as a new minimally invasive approach in 5 patients with aortic regurgitation since September 2012. The mean age was 63 years (range 25-84 years). TAX AVR was performed through 7 cm skin incision along the right anterior axillary line, and small 4th intercostal thoracotomy. Cardiopulmonary bypass was established through the femoral artery and vein. Intra-thoracic procedures were performed under direct vision, or videoscopic assistance with the aid of minimally invasive surgical apparatus. The mean operative time was 312±44 min, cardiopulmonary bypass 217±38 min, and cross-clamp 139±22 min. The mean ventilation time was 4.2±6.1 h, and length of post-operative hospital stay was 14.8±0.9 days. There was no re-operation for bleeding, or conversion to median sternotomy. TAX AVR can avoid sternotomy, transection of rib, and sacrifice of internal thoracic artery. The postoperative wound was unrecognizable unless the right arm was raised. This approach may promise patients' early rehabilitation and better cosmetic results.

Four cases of atopic dermatitis successfully treated with the Kampo formula Tokaku-joki-to are reported. Case 1 was a 25-year-old woman who had been suffering from atopic dermatitis since she was in lower elementary school. She came to our clinic in July of 1992. She complained of intense itching of the neck and area around the mouth. Her abdominal tension was moderate, and there was para-umbilical and caecal tenderness. The patient complained of constipation and dysmenorrhea. After four weeks of Tokaku-joki-to administration, the dermatitis improved markedly. After two years of treatment with this formula, she is progressing favorably.
Case 2 was a 14-year-old girl, who had suffered from atopic dermatitis since she was 3 months old. She first came to our clinic in January of 1993. The dermatitis was located in the upper extremities, face and neck. She also had experienced flushing, para-umbilical tenderness and constipation. After two weeks of administration of Tokaku-joki-to, her dermatitis improved remarkably, although she still experienced flushing. Ryokei-mikan-to was added to the formula for the flushing.
Case 3 was a 28-year-old woman who had suffered from atopic dermatitis since she was 3 years old. She consulted our clinic in October, 1993. The dermatitis was located on her face and elbow. She had tenderness around the paraumbilical, caecal and sigmoid regions. The patient is progressing favorably with Tokaku-joki-to administration.
Case 4 was a 26-year-old woman. She had had atopic dermatitis since she was young, and came to our clinic in October of 1993. The dermatitis was on the upper extremities, face and back. At first we prescribed Toki-inshi, but this formula was not effective. The formula was changed to Tokaku-joki-to and the dermatitis improved remarkably after about three months of treatment.
This is the first report of administering Tokaku-joki-to for atopic dermatitis. Based on the clinical study involving the four cases described above, we propose the following indications for use of Tokaku-joki-to for atopic dermatitis: 1) the dermatitis is located on the upper part of the body, 2) there is flushing, with a feeling of coldness in the lower extremities, 3) there is tenderness around the para-umbilical, caecal and sigmoid regions, and 4) there is a tendency towards constipation.

In Kampo therapy for rheumatoid arthritis (RA), Keishi-ka-ryojutsubu-to, Keishini-eppi-itto and Keishi-shakuyaku-chimo-to are considered to be the primary formulas. However, it is often difficult to control arthritis with the primary formula alone. In this study, we administered 7.5g/day of Ji-daboku-ippo to 12 patients with RA, who had not responded sufficiently to the primary formula alone. Administration of the primary formula and other anti-rheumatoid drugs was also continued.
After three months of this supplemental administration of Ji-daboku-ippo, the mean±SE of the Lansbury's index significantly decreased from 45.3±5.8% to 33.3±3.8% (p<0. 01). After treatment for one year, a decrement in the Lensbury's index (of more than 20%) was seen in the four patients. These results suggest that supplemental administration of Ji-daboku-ippo is effective for patients who fail to respond sufficiently to the primary Kampo formulas used for RA.

We present here two cases of rheumatoid arthritis (RA) treated with Shikunshi-to-ka-keishi-shakuyaku-yokuinin. Case 1 was a 71-year-old female who had been suffering from RA for two years and had been treated with western medicines. Keishi-ni-eppi-itto-ka-ryojutsubu-to offered some degree of palliation at first, but soon came to cause itchy eruptions and anorexia. On the other hand, treatment with Shikunshi-to-kami-ho (described above) for nine months achieved complete remission without any adverse reactions. Case 2 was a 52-year-old female who was diagnosed as RA in 1989 and had discontinued treatments with a variety of DMARDs (disease modifying anti-rheumatic drugs) because of adverse reactions such as eruptions, anorexia, and loss of hair. Moreover, many Kampo medicines with low-dose steroids were less effective. Shikunshi-to-kami-ho, which was administered after Kampo-medicine-induced liver damage, produced clinical effects to some degree. Shikunshi-to-kami-ho may be useful in the treatment of RA patients who have developed adverse reactions such as eruptions, liver damage, and anorexia.

We assessed the understanding of Japanese Oriental Medicine, as well as the connection between General Medicine and Japanese Oriental Medicine, among medical students, to improve the effectiveness of clinical practice and lectures. The questionnaires were sent to fifth-year medical students (n=66), and the responses were collected anonymously. Although 22.4% of the responding students were “very” interested in Japanese Oriental Medicine and 68.7% were “slightly” interested, the students who understood Japanese Oriental Medicine even “slightly”comprised only 23.9%. The majority of students considered that the system of Japanese Oriental Medicine was most useful in combination with Western Medicine for practicing General Medicine. Nine (60%) of 15 students who understood Japanese Oriental Medicine considered that the system of Japanese Oriental Medicine was most useful for practicing general medicine. In contrast, among students who did not understand Japanese Oriental Medicine, only 8 of 42 (19%) showed the same response. Similarly, more of the students who understood General Medicine showed this response than students who did not understand General Medicine.
These results permit us to speculate that medical students consider that understanding both General Medicine and Japanese Oriental Medicine might contribute to the development of a medical service.

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.

Diffuse hepatic arteriovenous malformation is extremery rare disease. A 69-year-old female was admitted to Nagoya Ekisaikai Hospital because of heart failure in NYHA class III. A selective celiac angiogram, echo cardiography and cardiac catheterization revealed high output cardiac failure secondary to diffuse hepatic areteriovenous malformations. Hepatic artery embolization with steel coils was performed. This resulted in amelioration of heart failure.