1)In the 2008 academic year, we developed a new narrative-based medicine (NBM) curriculum at Sapporo Medical University.
2) The program includes lectures on the concept of NBM, the clinical practice of NBM, and the illness narratives of patients' families, and exercises in narrative competence (significant event analysis, parallel chart, and life story).
3) Although some students had negative attitudes about the program, most students evaluated the course positively. We need to continuously improve the curriculum to develop narrative competence in medical students.

A 22-year-old man was hospitalized due to severe back pain having being diagnosed as Stanford type A aortic dissection, AAE, mitral regurgitation and pectus excavatum associated with Marfan's syndrome. A single staged operation including ascending aortic replacement, mitral valve replacement and sternal turnover with a rectus muscle pedicle was carried out in order to keep the blood supply to the plastron to reduce the risk of infection during such a long operation. By this approach, it was found that the operative field was excellent and postoperative hemodynamics were stable. However, frail plastron occurred because of difficulties in keeping the patient stabilized because of severe pain thus re-fixation was required. The necessity of strong pain control after such an operation was also recognized.

Three cases of LMCAP for the isolated LMCA stenosis were presentd. In two cases of the proximal LMCA stenosis, the connective tissue between the ascending aorta and the main pulmonary artery was prepared to detect the LMCA. From the left lateral wall of the ascending aorta to the anterior wall of the LMCA over the stenotic lesion was excised and the saphenous vein patch was sutured (anterior approach). In the third case, because the stenosis was locarized at the distal LMCA, the patch angioplasty using the saphenous vein was performed by direct opening of the distal LMCA accessed from the left lateral side of the main pulmonary artery without aortotomy (lateral approach). Ultrasonic cuser was quite useful to isolate the LMCA. LA-LV vent was indispensable to obtain the non-blood clean operation field. All three cases showed the successful enlargement of LMCA at the postopeorative coronary angiography.

Our experience with 13 patients (mean age 52, range 35-71 years) undergoing pericardiectomy at Mitsui Memorial Hospital in the 13 years (from 1977 to 1990) has examined with clinical features and M-mode echocardiographic study. Preoperatively, the patients were either in N. Y. H. A. Functional Class III (11 cases), or Class IV (2 cases). Median sternotomy without using cardiopulmonary bypass was employed in all cases. The area of the right ventricle, atria, cavae, pulmonary veins and left ventricle where can be reached without cardiopulmonary bypass or other hemodynamic support were decorticated completely, and the posterior portion of the left ventricle were not decorticated partially. Intraoperative hemodynamic responses were observed between before and after pericardiectomy monitored by Swan-Ganz catheter; central venous pressure (CVP) were changed from 21.3±5.6 to 13.6±4.0cmH₂O, pulmonary artery diastolic pressure (PADP) were changed from 19.8±5.5 to 11.3±6.6mmHg, cardiac index (CI) were changed 2.14±1.34 to 3.16±1.73l/min/m². There were no early deaths and no late heart complicated deaths. There were 2 cases died, one for advanced gastric carcinoma and another for wide cerebral infarction whthin 3 years from pericardiectomy. M-mode echocardiographic study that were examined between preoperative and late postoperative periods (mean follow-up time 51 months) showed effective recovery in cardiac function; left ventricular end-diastolic volume index (LVEDVI) were from 34.3±12.1 to 39.5±14.5ml/m², left ventricular end-systolic volume index (LVESVI) were from 17.2±7.8 to 13.1±6.7ml/m², stroke index (SI) were from 17.1±7.3 to 26.6±12.5ml/m², ejection fraction (EF) were from 45.1±19.2 to 61.2±22.5%, mean velocity of circumferential fiber shortening (mean Vcf) were from 0.80±0.35 to 1.13±0.53circ/sec. All the patients showed functional improvement; 9 are in N. Y. H. A. Functional Class I, and 4 are in Class II. These findings would be permitted this procedure with median sternotomy for chronic constrictive pericarditis as one of a safety and effective method conventionally.

The authors employed a modified CABG procedure to avoid cerebral infarction in cases of calcified ascending aorta. Among 348 cases of CABG surgery, we used the modified procedure in 14 cases (4%). The mean age was 66. Four patients had a history of previous stroke and one patient had arteriosclerosis obliterans. Our strategy is, (1) use femoral or aortic arch cannulation for cardiopulmonary bypass (CPB), (2) maximal use of in-situ arterial graft, (3) graft-coronary anastomosis under ventricular fibrillation (Vf) without aortic cross clamp, (4) proximal anastomosis of saphenous vein graft (SV), if used, was made at the arterial graft, otherwise direct anastomosis to the aorta was made under circulatory arrest. The internal thoracic artery (ITA) was used in 18 cases and the gastroepiploic artery (GEA) was used in 8 cases, SV was used in 4 cases. The mean Vf time was 48min and mean CPB time was 94min. The peak CPK was 805U and the peak CPK-MB was 52U. There was no significant difference between modified and conventional procedures in terms of operation time and myocardial protection. No cerebrovascular complication was noted with the modified procedure. In conclusion, the modified technique is safe for atherosclerotic-ascending aorta in CABG.

We performed surgical treatment for 21 patients of airway obstructions associated with congenital heart disease from December 1986 to March 1993. In all patients perioperative bronchoscopy demonstrated the cause and site of airway obstructions. Seven patients with corrective cardiac surgery (7/7), 7 with palliative cardiac surgery (7/10) and 2 with surgery for airway diseases (2/4) could be weaned from respirators following surgical treatment. Five patients died postoperatively. A respirator was required in 16 patients (76%) preoperatively. The suspension of pulmonary artery with intraoperative bronchoscopy was carried out in 6 patients. Five (5/6) were successfully extubated earlier postoperative day (mean 8.4 days), whereas only five in 10 patients without that procedure could be weaned from the respirator at a mean of 2 months. Identification of potential airway obstruction and early extubation is needed to reduce the mortality and morbidity caused by airway obstruction associated with congenital heart disease. Preoperative bronchoscopy is useful for diagnosis of airway obstructions and essential for decision making concerning surgical treatment. To early extubation in patients with marked airway obstructions, we recommend appropriate choice of the surgical procedure combined the suspension of pulmonary artery.

Seven patients with congenital heart defects suffered from multiple major hemorrhages from the lung after surgery and 5 of them died at 8 to 54 postoperative days because of respiratory insufficiency. In a patient with tetralogy of Fallot associated with pulmonary atresia, bleeding occured after the second shunt operation, presumably from rupture of bronchial collateral vessels. The clinical diagnoses of the other 6 patients were coarctation of the aorta (CoA) with common atrioventricular canal (CAVC) in 1, triple shunt in 1, persistent truncus arteriosus in 2, total anomalous pulmonary venous connection in 1 and CAVC in 1. Subclavian flap aortoplasty was performed without pulmonary artery banding in the patient with CoA and CAVC, whereas complete repair was performed in the other 5 patients. As these patients were associated with severe pulmonary hypertension preoperatively and 4 of them encountered pulmonary hypertensive crisis, the hemorrhage from the lung may be related to pre and postoperative high pressure of the pulmonary artery. Dilatation and rupture of the pulmonary capillary net was demonstrated in the patient with CoA and CAVC. These findings suggest the hypothesis that bleeding occurred due to rupture of the capillary net as a result of transmission of high pressure. Major bleeding from the lung is a rare but catastrophic complication after repair of congenital heart defects. As the treatment is difficult, early surgical intervention and treatment of postoperative pulmonary hypertension are important in complex lesions with severe pulmonary hypertension.

The incidence of ventricular subepicardial aneurysm following myocardial infarction is quite low. We report a case of subepicardial aneurysm that was diagnosed on postoperative pathohistologic examination. A 69-year-old man was admitted to our hospital because of left ventricular aneurysm following myocardial infarction. The patient had left main trunk disease, triple-vessel coronary artery desease and low output syndrome. Under cardiopulmonary bypass with the heart arrested, the aneurysm was resected and the defect was closed. The suture line was reinforced using Teflon felt and GRF glue. A saphenous vein graft was anastmosed to the left anterior descending artery. On pathohistologic examination, the wall of the aneurysm was found to be composed of fibrotic tissue, myocardial fibers, medium-sized pericardial arteries, epicardium and fibrin thrombi. We diagnosed this as subepicardial aneurysm.

Under scheduled anticoagulation therapy, surgery for abdominal aortic aneurysm was performed in 4 patients who had undergone heart valve surgery and implantation of a mechanical prosthesis. Warfarin and antiplatelet agents were prescribed in all cases preoperatively. Antiplatelet agents were discontinued from seven to 10 days before operation. Warfarin was stopped from two to three days before operation and heparin (200IU/kg/day) was administered by continuous intravenous infusion to produce an activated clotting time of around 150 seconds. Bolus intravenous heparin of 3, 000 IU was added before aortic crossclamp. Oral anticoagulants were resumed from the beginning of oral intake, and heparin was stopped when the prothrombin time reached therapeutic levels (% PT=40%). In three patients perioperative courses were uneventful. Intraperitoneal hemorrhage occurred in one patient who simultaneously underwent cholecystectomy and aneurysmectomy with Y-grafting. He required blood transfusion and interruption of anticoagulation. Brain thromboembolism occurred in this patient 26 days after the operation. We believe that scheduled anticoagulation for the operation of abdominal aortic aneurysm is safe and useful in patients with prior prosthetic heart valve surgery. However, the coexistence of coagulopathy requires more intensive anticoagulation therapy.