Background: A review committee for unapproved and off-label drugs with high medical needs determined that the indication of fibrinogen concentrate for cardiovascular surgery would be publicly acceptable in 2021. However, the Japanese Society of Cardiovascular Surgery is required the conduct of several surveys demonstrating that fibrinogen concentrate can be used properly in medical settings. A questionnaire concerning the use of fibrinogen concentrate in cardiovascular surgery was one such required survey. Methods: A questionnaire concerning the use of fibrinogen concentrate was conducted in December 2021 at 551 certified training facilities of the Japanese Board of Cardiovascular Surgery, and responses were received from 375 facilities (68%). Results: Fibrinogen concentrate was used in 98 centers (26%). Aortic surgery (thoracic/thoracoabdominal) (50%) and cardiac redo surgery (24%) were eligible common surgeries requiring fibrinogen concentrate, and the intraoperative measurement of fibrinogen levels was performed in 77% of centers. The triggers for the use of fibrinogen concentrate were a fibrinogen level <150 mg/dl in 30%, <100 mg/dl in 20% and massive bleeding tendency in 40%. Of note, only 39 facilities (10%) were able to prepare cryoprecipitate in-hospital, and 34 centers (9%) used it for cardiovascular surgery. One hundred and seven centers (29%) planned to apply for facility accreditation for the use of fibrinogen concentrate, and 40 facilities (10%) answered that they would decide based on the situation. The expected number of annual cases in which fibrinogen concentrate would be used for cardiovascular surgery reached 4,860 cases: <10 cases in 52 centers, 10-19 cases in 50 centers, 20-49 cases in 31 centers, 50-99 cases in 12 centers and ≥100 cases in 2 centers. Conclusion: We conducted a questionnaire on the use of fibrinogen concentrate. Intraoperative fibrinogen level measurement was performed at approximately 80% of institutions, and the annual number of cases likely to use fibrinogen concentrate was predicted to reach about 5,000 cases. However, only 10% of centers used cryoprecipitates prepared in-hospital.

The purpose of this study is to assess the impact of coronavirus disease 2019 (COVID-19) on the performance of cardiovascular surgery in Japan. The information gathered may be useful to prepare for a surgery in Severe Acute Respiratory Syndrome Coronavirus 2 (SARS-CoV-2) positive patients and prevent COVID-19 transmission from surgical patients to healthcare workers. [Methods] A web-based questionnaire was distributed to all accredited cardiovascular surgery centers in Japan. A total of 550 questionnaires were sent, and 310 (56.4%) were returned. [Results] Preoperative PCR or antigen testing was performed in all patients at 68.8% of centers. The proportion of surgeries postponed or cancelled was the highest for elective valvular and aortic surgeries and for emergency aortic surgeries. In most facilities elective surgeries were restricted to less than 50% of usual case volumes, while approximately 40% did not experience any negative impact on the case volume. Among the surgical patients, 32 were suspected to be SARS-CoV-2 positive, and 10 were confirmed. As preventive measures against spreading infection, more than 90% of the patients wore N95 masks, 33.3% full PPE, and 66.7% N95 mask+face shield. No case of patient-to-healthcare-worker transmission was reported. There were no postoperative deaths among the confirmed SARS-CoV-2 patients. [Conclusion] Restriction of surgical practice was placed on many institutions in the COVID-19 pandemic, but the degree of restrictions varied. Preoperative screening of all surgical patients and intraoperative use of PPE in those with suspected or confirmed SARS-CoV-2 infection adequately prevented transmission to healthcare workers. Since COVID-19 has a nationwide impact, it is important to continuously monitor surgical outcomes and infection rate by conducting perioperative surveys of COVID-19 patients.

A 57-year-old man complained of dyspnea, and his echocardiography showed diffuse severe left ventricular dysfunction. Five days after admission and starting the treatment for congestive heart failure, a computed tomography pointed out DeBakey type 1 aortic dissection with a patent false lumen incidentally. The ostium of the left coronary artery was compressed with the false lumen, and this finding was thought to be a cause of development of left ventricular dysfunction. A modified Bentall procedure with bioprosthesis and total arch replacement were performed. The patient was discharged on the 28th postoperative day without any complications.

A recent fatal accident related to the use of the pulmonary artery catheter (PAC) promoted us to conduct a questionnaire survey to assess the current use of the PAC and its complications during cardiac surgery. Methods : A 10-item questionnaire was distributed to all board-certified cardiovascular surgery centers in Japan. Five hundred thirty-two questionnaires were distributed and 325 (61.1%) were returned. Results : Seventy-two percents of hospitals used the PAC in more than 90% of cases, while only 17% used it less than 50% of the time. Indication of its use was not clearly determined in 52% of hospitals. Entrapment of the PAC was experienced in 28% of centers in the last 10 years, and its incidence was calculated as 0.07%. At a quarter of hospitals, checking for PAC to confirm absence of entrapment was not performed during the operation. Pulmonary artery rupture occurred at 22% of hospitals, and its incidence was 0.05%. Agreements on handling PAC to prevent cardiac injury or pulmonary artery rupture were not made in 24 and 56% of hospitals respectively. Conclusion : These data demonstrate that in many of the cardiac surgery centers in Japan, the PAC is still routinely used. Serious complications including catheter entrapment and pulmonary artery injury were encountered in a substantial number of patients. Development of guidelines for PAC during cardiac surgery to limit its use to patients with clear benefits and prevent related complications is warranted.

Purpose : Recently, the Japanese government has promoted reform of working practices. The working environment of medical professionals was no exception. In the present study, we investigated the current working environment and issues of cardiovascular surgeons, who are supposed to be working in one of the most demanding circumstances in Japan. Methods : In December 2018, the Japanese Society for Cardiovascular Surgery (JSCVS) sent a questionnaire to all JSCVS members via the internet to obtain basic data on the working environment including working hours, working items, income, and the issues to be solved for cardiovascular surgeons in Japan. Results : The JSCVS received responses from 634 cardiovascular surgeons (response rate 17%, 589 males/38 females). Respondents were primarily mid-career surgeons in their age of 40 s and 50 s. Four hundred seventy-three respondents (75.5%) and 176 respondents (28.2%) answered that they worked an average of 60 and 80 h a week, respectively. In addition, 249 respondents (40.4%) reported receiving no allowance for on-call work during off hours, after midnight, or on a holiday, while 345 respondents (56.6%) reported receiving no allowance for emergency surgery during off hours, after midnight, or on a holiday. Conclusion : Over 75% of cardiovascular surgeons reported being overworked without receiving an appropriate amount of income. Along with the reform of working style being made for the Japanese people, improving the working environment of cardiovascular surgeons is also an urgent matter to maintain healthcare for cardiovascular disease. Facilitating understanding of the issue by the Japanese people is of the utmost importance for the JSCVS.

Retrograde type A aortic dissection (RTAD) following thoracic endovascular aortic repair (TEVAR) is a lethal complication. A 54-year-old woman with bovine aortic arch presented with dilatation of the descending aorta due to chronic type B aortic dissection. She underwent TEVAR in zone 2 for closure of the entry site just below the origin of the left subclavian artery. On the day after TEAVR, she showed right hemiparesis, and was diagnosed with cerebral infarction on MRI and RTAD on CT. She underwent an emergent operation. The entry was at the proximal end of the bovine trunk, where the edge of the bare stent stuck out. We performed partial arch replacement with entry resection. Her postoperative course was uneventful. She was transferred to another hospital for rehabilitation 37 days after the surgery.

STUDY DESIGN: Retrospective study. PURPOSE: We experienced the situation wherein some patients had new-onset pain or dysesthesia around the ring and little fingers (C8 symptom) or ulnar aspect of the forearm (T1 symptom) after cervical laminoplasty (LP). We investigated the incidence and the cause of new C8 or T1 symptoms and the clinical outcomes after C3–C6 LP or C3–C7 LP. OVERVIEW OF LITERATURE: There were some reports regarding complications after cervical LP. However, there was no report regarding C8 or T1 symptoms after cervical LP. METHODS: Among the 33 patients enrolled in this study, 11 and 22 patients were treated with C3–C6 LP and C3–C7 LP, respectively. We prospectively evaluated C8 or T1 symptoms daily postoperatively for 1 week. The distance of the posterior spinal cord shifting and posterior subarachnoid space from C2 to T1 was measured by T2-weighted midsagittal magnetic resonance imaging (MRI). We evaluated pre- and postoperative axial neck pain, Japanese Orthopaedic Association (JOA) score, and JOA score improvement rate. RESULTS: C8 or T1 symptoms occurred in five and three patients with C3–C6 LP (45.5%) and C3–C7 LP (13.6%), respectively. The distance of the posterior subarachnoid space in C3–C6 LP at C7 was significantly shorter than that in C3–C7 LP at T1 on MRI 24 hours postoperatively (p=0.0448). Postoperative axial neck pain, pre- and postoperative JOA scores, and JOA score improvement rate were not significantly different. CONCLUSIONS: The incidence of C8 or T1 symptoms in C3–C6 LP was higher than that in C3–C7 LP. C8 or T1 symptoms would be caused by the posterior fila radicularia and spinal cord impingement on the intact lower end of the lamina.
Asian Continental Ancestry Group ; Fingers ; Forearm ; Humans ; Incidence ; Laminoplasty ; Magnetic Resonance Imaging ; Neck Pain ; Paresthesia ; Prospective Studies ; Retrospective Studies ; Spinal Cord ; Subarachnoid Space

A 42 year-old woman with Marfan syndrome, who had replacement of the ascending aorta for acute aortic dissection several years ago, was found to have distal aortic arch aneurysm. The aneurysm had small entries at cervical arterial branches and large re-entry at the left external iliac artery. It was necessary to perform two-staged operation Bentall procedure with total arch replacement and abdominal aortic replacement with re-entry closure. It was usually performed with a primary entry closure for chronic aortic dissection, but massive invasion was expected. We performed catheter angiography for entry and re-entry, and decided to perform preceding re-entry closure. First, we underwent replacement of the abdominal aorta, and then successfully performed the Bentall procedure with total aortic arch replacement. The catheter angiography was useful for decision-making for medical treatment.

Thirty two years-old man with arthralgia in both hands was given with non-steroid anti-inflammatory drug and followed. The symptoms persisted, and hematuria and signs of infection were getting apparent. The patient was referred to our hospital with increasing dyspnea. The patient presented acute heart failure, acute renal insufficiency and respiratory failure. Echocardiography revealed vegetation and regurgitation in the aortic and mitral valve. Blood culture demonstrated α-Streptococcus. CT revealed enlargement of the aortic root. The patient was diagnosed with infectious endocarditis, and referred for surgery. At surgery, the aortic valve and mitral valve were severely destroyed. Aortic root and mitral valve replacement were performed. Pathological findings demonstrated valve destruction as a result of endocarditis due to active rheumatic fever. Clumps of bacteria were not noted around the valves. This is a rare adult case with valve destruction by acute rheumatic fever.