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.

Purpose: Surgery of the horseshoe fistula is challenging due to its complex configuration and sphincter muscle involvement. Complete deroofing fistulotomy for horseshoe fistula is highly curative with the eradication of all fistulous lesions but has been discredited for its high incontinence rate. It was replaced with the more conservative Hanley’s procedure leaving the lateral tracts intact, despite its issue of recurrence. Our study aimed to report the outcomes of a procedure dividing complete deroofing fistulotomy for horseshoe fistula into 2 stages to avoid impairment of sphincter function. Methods: We retrospectively reviewed 139 patients who underwent surgery for horseshoe fistula using the 2-stage complete deroofing fistulotomy method between 2014 and 2017. The first surgery deroofed the lateral tracts with an arch-like incision severing the anococcygeal ligament. The primary lesion was also drained and curetted. A seton was placed in the primary tract which was laid open in the second surgery after the lateral wound had partially healed. Results: Recurrence was observed in 12 patients. All were superficial recurrences except for 1, in which recurrence was confirmed in the primary lesion. Those with blind intersphincteric upward extensions had a significantly higher recurrence rate. Furthermore, patients who resided far from the hospital and could not make visits for frequent wound inspections also had a significantly higher recurrence rate. No patient had any continence issues at the end of the follow-up period. Conclusion Managing horseshoe fistula with the 2-stage deroofing fistulotomy approach allows for eradication of the fistula tract without compromising anal sphincter function.

Purpose: Surgery of the horseshoe fistula is challenging due to its complex configuration and sphincter muscle involvement. Complete deroofing fistulotomy for horseshoe fistula is highly curative with the eradication of all fistulous lesions but has been discredited for its high incontinence rate. It was replaced with the more conservative Hanley’s procedure leaving the lateral tracts intact, despite its issue of recurrence. Our study aimed to report the outcomes of a procedure dividing complete deroofing fistulotomy for horseshoe fistula into 2 stages to avoid impairment of sphincter function. Methods: We retrospectively reviewed 139 patients who underwent surgery for horseshoe fistula using the 2-stage complete deroofing fistulotomy method between 2014 and 2017. The first surgery deroofed the lateral tracts with an arch-like incision severing the anococcygeal ligament. The primary lesion was also drained and curetted. A seton was placed in the primary tract which was laid open in the second surgery after the lateral wound had partially healed. Results: Recurrence was observed in 12 patients. All were superficial recurrences except for 1, in which recurrence was confirmed in the primary lesion. Those with blind intersphincteric upward extensions had a significantly higher recurrence rate. Furthermore, patients who resided far from the hospital and could not make visits for frequent wound inspections also had a significantly higher recurrence rate. No patient had any continence issues at the end of the follow-up period. Conclusion Managing horseshoe fistula with the 2-stage deroofing fistulotomy approach allows for eradication of the fistula tract without compromising anal sphincter function.

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.

A 67-year-old man was admitted with right heart failure. He had severe peripheral edema of his lower limbs. The heart failure was treated by diuretics, but after 3 months, he was re-admitted with facial edema and pleural effusion. At this time, the pericardium thickened diffusely and rapidly, constricting the heart. Pericardiectomy was performed to alleviate symptoms of heart failure. The thickened pericardium firmly adhered to the epicardium, from which it was inseparable. A partial pericardiectomy was done. The diagnosis was not confirmed during operation, but primary malignant pericardial mesothelioma was diagnosed on immunohistological examination with carletinin. The patient died from massive pleural effusion and heart failure on the 22nd postoperative day. Primary malignant pericardial mesothelioma is an extremely rare pathology, which is difficult to diagnose and has a poor prognosis. However, this pathology is the disease which we should always mention as a cause of constrictive pericarditis.

A 64-year-old man who had chronic aortic dissecting aneurysm with true lumen obstruction of the abdominal aorta was referred to our hospital for surgery. He underwent total aortic arch replacement with the elephant trunk technique using an aortofemoral artery bypass as a first-stage operation. Reconstruction of the thoracic aortic descending aneurysm using the previous elephant trunk graft in a second-stage operation was feasible. His perioperative course was uneventful and he had no neurologic complications.

Acute aortic dissection complicated with acute myocardial infarction in a case of 61-year-old woman with an aberrant right coronary artery was successfully treated by emergency operation fore type A acute aortic dissection. However, cardiogenic shock and bradycardia occurred after induction of anesthesia due to right ventricle myocardial ischemia. Cardiopulmonary bypass was established quickly and deep hypothermia was induced. We also perfused the right coronary artery with an external shunt tube to prevent the progression of the right ventricular infarction. The right coronary artery, which originated above the left coronary sinus, was dissected totally. We performed ascending and aortic arch replacement and coronary artery bypass grafting with a saphenous vein graft to the right coronary artery under hypothermic circulatory arrest. She had no major reduction of cardiac function. Although it was a rare combination, aberrant right coronary artery was vulnerable to myocardial ischemia associated with acute type A dissection. The external coronary shunt tube was useful for this type of myocardial ischemia.

Although atrial fibrillation is a complication frequently encountered after cardiac surgery in routine practice, no effective measure is available to prevent its onset, and surgeons often have great difficulties in managing their patients with this condition. On suspicion of the involvement of increased sympathetic activity in the onset, the pre-onset status of 57 patients was examined. The patients were supposedly at low risk of developing atrial fibrillation after cardiac surgery. Additionally, plasma concentrations and 24-hour cumulative urinary excretion of norepinephrine, a biochemical indicator of sympathetic activity, were measured before surgery and on days 3 and 7 of disease. As a result, a group of patients with atrial fibrillation were found to have higher pre-onset heart rates and significantly increased plasma norepinephrine concentrations and 24-hour cumulative urinary norepinephrine excretion compared to controls. Hence, increased sympathetic activity is considered to play a major role in the onset of atrial fibrillation following cardiac surgery.

An 83-year-old man had acute type B aortic dissection combined with a large athelosclerotic abdominal aortic aneurysm (AAA) over 8cm in diameter. The dissection advanced into the wall of the AAA. The patient was treated with strict medical therapy for two months and successfully underwent an early elective abdominal aortic repair concomitant with off-pump aortocoronary bypass grafting. This strategy of meticulous medical management may improve clinical outcome for the acute phase in such rare cases.

A 62-year-old woman presented with acute chest pain. An enchanced CT scan showed type A closing aortic dissection. An ulcer-like projection (ULP) was observed in the abdominal aorta above the superior mesenteric artery on aortography. At 3 months after onset, recurrent chest pain appeared. An enchanced CT scan showed a false lumen in the ascending aorta and a new ULP and localized false lumen were opacified in the distal ascending aorta on aortography. The graft replacement of the ascending aorta was performed using open distal anastomosis under circulatory arrest and retrograde cerebral perfusion. Two intimal tears were found in the aortic root and distal ascending aorta. The patient recovered without complications. Postoperative CT scan and aortography revealed no residual false lumen.