The U-40 generation of cardiovascular surgeons is receiving training as cardiovascular surgeons, including daily surgeries, ward responsibilities and other important tasks, young surgeons are on their way to becoming skilled cardiovascular specialists. However, it is said that it takes a long time to become a full-fledged surgeon, and in particular, the way to becoming a full-fledged cardiovascular surgeon varies greatly among individuals and is not standardized. Therefore, the U-40 generation is always concerned and worried about their future career development. At the 54th Annual Meeting of the Japanese Society for Cardiovascular Surgery, we will discuss what the U-40 generation needs to become full-fledged surgeons, what they are worried about, and how their seniors who are actually active as independent cardiovascular surgeons think and what their career paths have been like. I had an opportunity to reflect on the gap between the two. This time, we conducted a questionnaire survey to visualize the conditions and future prospects for becoming an independent surgeon as considered by the U-40 generation.

As part of U-40 activities, chapters have traditionally held sessions of lectures and hands-on as the Basic Lecture Course (BLC) to improve the basic skills and knowledge of young cardiovascular surgeons. Because of the COVID-19 epidemic, we have shifted our activities from onsite to online. This column focuses on “management of postoperative delirium and pain” in the lecture of “Postoperative Management in Cardiovascular Surgery” given by the Chubu Chapter in 2020. We summarize the lecture and report the results of a questionnaire survey of the U-40 members.

Since the beginning of cardiac surgery, retained intracardiac air has been one of the important problems to be solved. While transesophageal echocardiography enabled visualization of the air, and de-airing procedures have been routinely carried out, they appear to vary much among institutions and are not necessarily based on firm scientific evidence. Thus, “de-airing” was chosen as the theme of the 2016 CVSAP (Cardiovascular surgery and Anesthesia and Perfusion) Symposium and a nation-wide questionnaire survey was carried out prior to it. This paper reports the results of this survey and illustrates “the best de-airing” at present, based on the literature review. The collection rate of the questionnaire survey was high : 77.9% (278/357) and 83.3% (85/102) from major institutions of surgeons and anesthesiologists, respectively, indicating a high level of interest. More than 90% of both considered de-airing as important since adverse events related to air embolism were actually encountered, including some critical ones. Most routinely performed de-airing procedures are posture change, lung inflation and aspiration through the vent cannulae. Direct aspiration of air is carried out in only one-third of institutions. Carbon dioxide insufflation is performed in 82.5% of institutions, mostly at a rate of 2∼3 L/min. However, not a few surgeons are skeptical of its significance. While many surgeons are grateful for collaboration by anesthesiologists, some expect more information sharing between them. They also expect better comprehension of “de-airing” and timely manipulation of extracorporeal circulation system by clinical engineers to avoid undesirable events. Some surgeons expressed a wish for a convenient device for de-airing. Furthermore, some questions to be solved in the future were raised, including how meticulously the bubbles should be removed or how efficient carbon dioxide insufflation is.

A 60-year-old man complained of palpitation due to transitory atrial fibrillation. The annulo-aortic ectasia was recognized, and was getting enlarged to 52 mm. After an additional examination, membranous ventricular septal aneurysm was revealed. There was no evidence of thrombus, shunt, or infection in the membranous ventricular septal aneurysm. The valve-sparing aortic root replacement (reimplantation) and the patch-closure of the membranous ventricular septal aneurysm were performed. Stabilizing the subannular tissue by a Dacron patch made the reimplantation technique feasible. To secure a subannular suture line, 3 mattress stitches were passed inside-out through the Dacron patch, the fibrous rim of the membranous septum and the prosthetic graft again. He was discharged without any complication 12 days after the operation.

In Kampo medicine, a tongue examination, whereby the shape and color of the tongue is observed, is thought to reveal the constitution and condition of the patient. In Japan, numerous books on this tongue examination have been published. However, tongue findings are expressed differently in these books, and a standard description for such findings has yet to be established. A standard description would be useful when examining the tongue, and when educating students of Kampo medicine. We therefore compared how tongue colors and shapes were expressed in the Japanese literature on tongue examinations (12 publications).
Using these results, we have arrived at a standardized description for tongue findings in accordance with Kampo specialists of tongue diagnoses at many facilities. In the process, we focused on easily recognizable findings that can be noted with short clinical examination times, and that can also be understood by beginners.

A 13-year-old girl with congenital mitral incompetence had undergone valvoplasty using the De Vega technique at age 5. The patient was referred by the pediatric department due to recurrence of mitral incompetence. Transesophageal echocardiography indicated regurgitation from A2 and P3, mild mitral leaflet tethering and left ventricular dilatation. Intraoperative findings showed valvular agenesis of the posterior leaflet around P3. No leaflet prolapse was observed at A2, but leaflet P2 had fallen to the left ventricular side compared with leaflet A2, thereby inducing regurgitation due to coaptation gap. In a procedure similar to folding plasty, leaflet P3 was folded down and sutured to the annulus extending up to the posteromedial commissure. This technique not only controlled regurgitation at P3 but also improved the coaptation between A2 and P2. Annuloplasty was conducted using a 28-mm Physio-ring. Folding plasty may be an effective surgical option for patients with congenital mitral incompetence because a broad valve orifice area can be maintained because there is no need for annular plication.

Intercostal artery aneurysm is a rare disease, and is usually associated with aortic coarctation, trauma and infection. Until recently, diagnosis of the aneurysm had not been possible before rupture of aneurysm. However, recent advances in computed tomography (CT) and magnetic resonance imaging (MRI) have made it possible to diagnose this lesion. A 68-year-old man was admitted with an abnormal shadow on chest X-ray film. A chest CT scan showed an aneurysm beside the descending aorta, suggestive of intercostal artery aneurysm. Intraoperative inspection confirmed the diagnosis. The aneurysm was shown to be atherosclerotic in origin by postoperative histological examination.

A 67-year-old man was hospitalized due to congestive heart failure. The blood pressure was 180/72mmHg in the right arm and 100/70mmHg in the right leg. Aortography revealed that the aortic arch was completely interrupted just distal to the origin of the left subclavian artery and the descending aorta was clearly outlined by contrast medium coming from well-developed collateral vessels. There was no congenital anomaly such as PDA or VSD except for the interruption of the aortic arch. The final diagnosis was solitary interruption of the aortic arch (type A). An extra-anatomical bypass using a 16mm woven Dacron graft was placed from the ascending aorta to the descending aorta at the level of the diaphragm with cardiopulmonary bypass. The pressure gradient across the interruption disappeared immediately after opening the graft. Although he had perioperative myocardial infarction in the area of the right coronary artery, he recovered fully and when discharged he was in NYHA class 1 condition.

Among 232 patients undergoing repair for abdominal aortic aneurysms (AAA) during a 10-year period, 5 (2.2%) patients had evidence of inflammatory abdominal aortic aneurysms (IAAA). We examined their clinical course, laboratory, operative and histopathological findings, and considered possible correlations between their diagnosis and surgical treatment. Among these cases of IAAA, 2 patients complained of severe abdominal or back pain. The differential diagnosis from rupture of AAA was difficult in these cases. They also showed inflammatory signs in laboratory, operative and histopathological findings. Ultrasonography, computed tomography and magnetic resonance imaging appear to offer reliable means for diagnosing IAAA; In particular we could recognize the“Inflammatory mantle”in 3 cases, which indicated IAAA. In the surgical treatment, the presence of IAAA necessitates certain modifications in the surgical approach, in order to avoid injuring the retroperitoneal and abdominal structures. We could observe post-operative change in the thickness of the aortic wall, which decreases with time without anti-inflammatory agents.