Coronary artery disease is a significant health concern and can lead to death. Coronary artery bypass grafting (CABG) is the primary surgical treatment for this disease. However, the long-standing hypothesis that women face higher surgical mortality than men after CABG remains controversial. The universal healthcare system and the established national cardiovascular surgery registry of Japan provide a unique oppotunity to assess this supposition. This study aimed to re-evaluate this long-standing hypothesis. This nationwide observational retrospective study analyzed 40,796 primary elective CABG procedures performed in Japan between January 2019 and December 2023. It included 33,202 men (81%) and 7,594 women (19%). Data were sourced from the Japan Cardiovascular Surgery Database. Preoperative, intraoperative, and postoperative variables were analyzed to assess sex differences in operative mortality. The impact of the yearly procedure volume at each facility was evaluated. Operative mortality for elective CABG was 1.25% in men and 1.63% in women ( P =0.01), supporting higher operative mortality in women in Japan. Preoperatively, women had lower body surface area and smoking rates. No notable sex differences were observed in the choice of surgical procedure, cardiopulmonary bypass use, or graft selection. Postoperative mediastinitis occurred more frequently in women than in men. After adjusting for body surface area, the difference in mortality became insignificant. A multivariable logistic regression analysis controlling for age, body mass index, preoperative comorbidities, preoperative status, and the facility’s annual CABG procedure volume confirmed that a body surface area of <1.4 m 2 was a significant mortality risk factor, irrespective of sex. The higher proportion of women with a body surface area of <1.4 m 2 explained the higher mortality in this group compared to the cases in men. These findings support that extremely small body size is a mortality risk factor for CABG. Nationwide registry data from Japan revealed that female sex is not an independent predictor for CABG mortality. Higher mortality in women primarily reflects the overrepresentation of female patients with very small body sizes. These findings suggest that surgical procedures and anastomosis strategies for small coronary arteries can improve outcomes in all patients when optimized.

The surgical outcomes of aortic root replacement for Stanford type A acute aortic dissection( AAAD) remain unacceptable with a 30-day mortality rate of 20%. Additionally, in young patients requiring aortic root replacement for AAAD, the preservation of native valve is desirable, yet challenging to achieve in emergent surgery with poor preoperative status. Ideally, we aim to avoid aortic root replacement whenever possible, opting instead for partial remodeling even in cases necessitating incision into the aortic root. We present our surgical outcomes in the strategy for aortic root pathology due to AAAD. We conducted an analysis of 517 cases of AAAD surgery from 2002 to 2023, wherein 499 cases( 96%) underwent aortic root preservation, 10 cases( 1.9%) underwent partial remodeling, and 8 cases( 1.5%)necessitated emergent aortic root replacement. Of these, 13 cases underwent aortic root replacement after AAAD repair( 8 David procedures and 5 Bentall procedures), all demonstrating favorable surgical outcomes, including long-term results. We believe that this strategy for aortic root pathology holds significant merit, particularly in AAAD in young patients with enlarged aortic root.

We retrospectively study the outcome of left atrial appendage (LAA) preserving maze procedure, focus on thrombus formation in left atrium( LA), postoperative stroke, and LA function.PATIENTS AND METHODS:We studied 131 patients (mean age, 68.2y;77 men and 54 women) who underwent maze procedure for atrial fibrillation( Af) between 2008 and 2020. Full maze was performed for 116 patients with long-standing persistent Af or persistent Af. Pulmonary vein isolation alone was performed for 15 patients with paroxysmal Af. The mean follow-up period was 2.9( 10.1-0.4) years.RESULTS:In perioperative results, there were no death, cerebral infarction, and reoperation in this series. At discharge, 1 year, 3 years, 5 years, and 10 years after the surgery, sinus rhythm was maintained in 92%, 87%, 83%, 77%. Pacemaker was implanted in 8( early 3, late 5) patients. Despite adequate anticoagulant therapy, one patient developed cerebral infarction a month postoperatively. In other patients, there was no cerebral infarction in short-term nor long-term.CONCLUSIONS:The LAA preserving maze procedure was not a risk factor of cerebral infarction under appropriate medication. However, close follow-up is essential.

腹部大動脈瘤に対するEVARでは「10年以上の生命予後が期待される症例はEVARより外科手術を考慮する」がクラスIIbで推奨され，胸部大動脈瘤に対するTEVARでは解剖学的要件を満たす下行大動脈瘤に対するTEVARがクラスIで推奨され，B型大動脈解離に対するTEVARでは将来拡大が予測されるHigh risk uncomplicated症例はPreemptive TEVARがクラスIIaで推奨されている。

OBJECTIVE:To clarify the current status of surgical treatment of acute aortic dissection (AAD) in Japan through the Japan Cardiovascular Database analysis. METHODS:In total, 7194 patients who underwent surgical treatment for AAD in 2021, including type A (TAAAD) (n = 6416) and type B (TBAAD) (n = 778), were investigated. RESULTS:The median age was 70 years, with patients older than age 80 years constituting 21.7% and 23.4% of TAAAD and TBAAD cases. Emergency admission was 88.5% and 78.5%. Shock was found in 11.8% and 6.0%. Rupture/impending rupture occurred in 10.7%/6.0% and 24.0%/11.1%, respectively. Branch malperfusion was complicated in 10.4% and 25.2%. Open repairs were performed in 97.7% and 20.3%, whereas endovascular repairs were performed in 2.3% and 79.7%, respectively. In the increased prevalence of endografting procedures, neurological complications and renal failure occurred frequently after open repair with frozen elephant trunk for 29.9% and 50.3%. The operative mortality rate was 9.8% and 11.5% for open repair and 8.1% and 10.0% for endovascular repair. In patients with TAAAD, age older than 80 years, preoperative critical comorbidities, classical dissection, and coexisting chronic vital organ diseases were independent risk factors for mortality. In frozen elephant trunk procedures, neurologic complications and renal failure were frequent. The operative mortality was higher during the superacute phase within 1 or 2 hours from onset to arrival and between arrival and surgery. CONCLUSIONS:The current status of surgical treatments for AAD including the increased prevalence of endografting of thoracic endovascular aortic repair and frozen elephant trunk were demonstrated with favorable outcomes in the Japan Cardiovascular Database analyses.

Central MessageCardiovascular surgery training in Japan has been evolving to achieve the goal of establishing well-organized off-the-job and on-the-job training and standardized quality assessment of residents.PerspectiveCardiovascular surgery training in Japan has been evolving to achieve the highest quality training. Further efforts are necessary to increase the number of required cases for accreditation of the training programs, to introduce detailed milestones that are easily understood by surgical educators and residents, and to standardize the quality assessment of the technical and nontechnical skills.See Commentaries on pages 176 and 177. Cardiovascular surgery training in Japan has been evolving to achieve the goal of establishing well-organized off-the-job and on-the-job training and standardized quality assessment of residents. Cardiovascular surgery training in Japan has been evolving to achieve the highest quality training. Further efforts are necessary to increase the number of required cases for accreditation of the training programs, to introduce detailed milestones that are easily understood by surgical educators and residents, and to standardize the quality assessment of the technical and nontechnical skills. See Commentaries on pages 176 and 177. The history of cardiovascular surgery in Japan dates back to 1928 when Seo and associates first reported on surgeries for constrictive pericarditis in 3 patients, as described by Kimoto.1Kimoto S. Historical review of surgery of the heart and great vessels in Japan.J Jpn Assoc Thorac Surg. 1975; 23 (in Japanese): 341-359Google Scholar Unfortunately, the advancement of cardiac surgery was completely interrupted by World War II. During the 1950s and 1960s, however, Japanese cardiovascular surgeons made significant contributions to the clinical application of hypothermia and total circulatory arrest, along with the development of techniques of cardiopulmonary bypass.2Sakakibara S. Orihata H. Nakayama K. Ichii A. Saito H. First successful report of intracardiac repair of arterial septal defect under cardiac circulatory occlusion in the condition of artificial hibernation.Jap Med J. 1954; 8: 1598Google Scholar, 3Horiuchi T. Koyamada K. Matano I. Mohri H. Komatsu T. Honda T. et al.Radical operation for ventricular septal defect in infancy.J Thorac Cardiovasc Surg. 1963; 46: 180Abstract Full Text PDF PubMed Google Scholar, 4Hikasa Y. Shirotani H. Satomura K. Muraoka R. Abe K. Tsushimite K. et al.Open heart surgery in infants with an aid of hypothermic anesthesia.Arch Jpn Chir. 1967; 36: 495PubMed Google Scholar Starting in the 1970s, various innovative techniques were developed in Japan, including aortic annular enlargement by Konno and associates5Konno S. Imai Y. Iida Y. Nakajima M. Tatsuno K. New method for prosthetic valve replacement in congenital aortic stenosis associated with hypoplasia of the aortic valve ring.J Thorac Cardiovasc Surg. 1975; 70: 909-917Abstract Full Text PDF PubMed Google Scholar; right ventricle to pulmonary artery shunt for hypoplastic left heart syndrome by Sano and associates6Sano S. Ishino K. Kawada M. Arai S. Kasahara S. Asai T. et al.Right ventricle to pulmonary artery shunt in first stage palliation of hypoplastic left heart syndrome.J Thorac Cardiovasc Surg. 2003; 126: 504-510Abstract Full Text Full Text PDF PubMed Scopus (366) Google Scholar; and retrograde cerebral perfusion technique as an adjunct to deep hypothermic circulatory arrest by Ueda and associates.7Ueda Y. Miki S. Kusuhara K. Okita Y. Tahata T. Yamanaka K. Surgical treatment of aneurysm or dissection involving the ascending aorta and aortic arch utilizing circulatory arrest and retrograde cerebral perfusion.J Cardiovasc Surg (Torino). 1990; 31: 553-558PubMed Google Scholar Japan has a population of approximately 120 million people, with 28.4% older than 65 years of age; importantly, this cohort is expected to grow and reach 39.9% in 2060 (Figure E1).8Ministry of Internal Affairs and CommunicationsWhite paper information and communication in Japan from Ministry of Internal Affairs and Communications.https://www.soumu.go.jp/johotsusintokei/whitepaper/ja/h30/html/nd101100.htmlDate accessed: March 1, 2020Google Scholar Accordingly, the mean age of the Japanese cardiovascular surgical population increased from 67.0 years in 2007 to 70.6 years in 2018 and is expected to increase further in the near future. The number of cardiovascular surgery cases in Japan has steadily increased from approximately 19,000 cases in 1986 to 48,000 cases in 2000, and most recently to 69,000 cases in 2016 (Figure 1). The number of coronary artery bypass procedures peaked at 23,000 cases in 2002 and has gradually decreased since then, whereas steady growth has been observed in the number of valve and aortic surgeries. The number of congenital heart surgeries has slightly decreased over the past 10 years (Figure 1).9Committee for Scientific Affairs The Japanese Association for Thoracic Surgery Shimizu H. Endo S. Natsugoe S. Doki Y. et al.Thoracic and Cardiovascular Surgery in Japan: Annual report by The Japanese Association for Thoracic Surgery.Gen Thorac Cardiovasc Surg. 2018; 66: 581-615Crossref PubMed Scopus (48) Google Scholar There are 2 major cardiothoracic and cardiovascular societies in Japan: the Japanese Association for Thoracic Surgery (JATS) and the Japanese Society for Cardiovascular Surgery (JSCVS). Established in 1948, the JATS has been the driving force for innovation, scholarship, and education of cardiothoracic surgeons, as well as serving as the monitoring board of annual cardiothoracic surgery procedures and their outcomes.10Asano K. Thirty-year History of Japanese Association for Thoracic Surgery Published by Japanese Association for Thoracic Surgery.1977http://www.jats-org/anniversary/30/index.htmlDate accessed: January 28, 2021Google Scholar The JSCVS, founded in 1972, is an academic association that serves the needs of its members and of society as a whole. The JSCVS has collaborated with the JATS and the Japanese Society for Vascular Surgery (JSVS) in creating and promoting the Japanese Board of Cardiovascular Surgery (JBCVS) since 2002. For the last 8 years, the Council of the JSCVS has invited its members aged less than 40 years to present their opinions to the Council regarding educational policies, including quality assurance, improvement of their training system, and time frame of their training period. Supported by the JSCVS, JATS, and JSVS, the Japan Cardiovascular Surgery Database (JCVSD) was initiated in 2000. The US Society of Thoracic Surgeons National Database content was translated into Japanese, ensuring that the parameters were consistent with those used in the Society of Thoracic Surgeons database to permit comparisons of data between both countries in the future.11Nawata K. D'Agostino R.S. Habib R.H. Kumamaru H. Hirahara N. Miyata H. et al.First database comparison between the United States and Japan: coronary artery bypass grafting.Ann Thorac Surg. 2020; 109: 1159-1164Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar Data could be registered on-line with the support of the University Hospital Medical Information Network Center in Japan. In 2012, the JBCVS decided to use the data registered in the JCVSD for the JBCVS board certification or recertification process. In this system, all applicants must register their cases in the JCVSD, and the program directors must confirm the accuracy of the data from their own institutions. Using this system, applicants can easily download the number and category of cases, information necessary for board certification or recertification. With these changes, almost all of cardiovascular surgery cases in Japan have been registered in the JCVSD since 2013. The total numbers of registered adult and congenital data entries in the JCVSD until the end of 2019 are shown in Figures E2 and E3 and Table E1. All surgical trainees in Japan enter medical school after graduating from high school and are required to complete a 6-year medical school program. During the 2 to 3 months surgical rotation of the last 3 years of medical school, they are allowed to examine patients during rounds and scrub in the operating room under the direction of staff surgeons. However, they are not permitted to perform invasive procedures, focusing instead on simulator-based training. Before entering any subspecialty surgical training in Japan, candidates must complete an initial 2-year clinical internship, which comprises the major fields of medicine including surgery, psychiatry, and obstetrics and gynecology. Unlike the North American and European systems, thoracic surgery residency is separate from that of cardiovascular surgery in Japan. Until 2019, all candidates seeking cardiovascular surgery training were required to register as a general surgery resident and complete at least a 3-year course of general surgery and accumulate at least 350 cases (120 cases as operating surgeon) before entering cardiovascular surgery training (Figure 2). Moreover, residents in cardiovascular surgery are required to earn the Japanese Board of Surgery (JBS) Certificate before completing cardiovascular surgery training and taking the JBCVS exam. Unlike the United States, there is no independent organization like the American Board of Surgery in Japan. Instead, the JBS, under the auspices of the JSS, has been responsible for every aspect of general surgery training, including preparation of the curriculum, conducting written and oral examinations, board certification and renewal, and certification of surgical educators. In contrast, the JBCVS, endorsed by the JATS, JSCVS, and JSVS, was established as an independent organization in 2002 to assume the same role of the JBS in every aspect of cardiovascular surgery training and quality control of training programs and surgical educators. The JBCVS is financially maintained through the fees of new and renewal applications, as well as through the fees for certification of training programs. Neither these cardiovascular surgery societies nor the Japanese government plays a role in this process. Unlike the systems in the United States,12Brescia A.A. Lou X. Louis C. Blitzer D. Coyan G.N. Han J. et al.The thoracic surgery resident association: past contribution, current efforts, and future direction.J Thorac Cardiovasc Surg. August 31, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (6) Google Scholar Canada,13Noly P.E. Rubens F.D. Ouozunian M. Quantz M. Shao-Hua W. Pelletier M. et al.Cardiovascular surgery training in Canada: current state and future perspectives.J Thorac Cardiovasc Surg. 2017; 154: 998-1005Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar and the United Kingdom,14Zakkar M. Benedetto U. Angelini G.D. Murphy G. Shah R. Jahangiri M. et al.Cardiothoracic surgery training in the United Kingdom.J Thorac Cardiovasc Surg. 2019; 157: 1948-1955Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar there is no national residency review committee. Instead, the JBCVS monitors the quality of each program based on the requirements for the training program (Table E2). Furthermore, the members of the JBCVS perform audits of training programs, especially those with poor surgical outcomes or low numbers of applicant cases. The minimum training period in cardiovascular residency is 3 years; however, residents usually continue their training for 4 to 8 years to fulfill the requirements for application for the JBCVS board exam (Tables 1, 2, and E3, and Figure 2) and to earn 500 points of surgical experiences (Tables 3 and E3) because the majority of training programs involve 100 to 250 cases per year. The length of the training period depends primarily on the case volumes of the training program, and a few residents who are fortunate enough to train in high-volume programs can reach 500 points of surgical experiences in 3 years. Therefore, the number of residency graduates varies each year because the number of candidates for the JBCVS who fulfill the stated requirements changes from year to year (Table 1, Table 2, Table 3). For example, graduates in the last 4 years were 183 in 2016, 176 in 2017, 156 in 2018, and 133 in 2019. The passing rate for the JBCVS written exam ranged from 77% to 87% during the last 5 years; there is no JBCVS oral exam. During residency, there is no in-service exam; the trainees learn though the Self-Education, Self-Assessment in Cardiovascular Surgery, which is equivalent to the SESATS in the United States.Table 1Training points depend on the procedure classification and trainee role in surgeryProcedure classificationABCSurgeon345First assistant1.522.5Second assistant0.30.40.5Operation score is as per table. The surgeon is the one who actually performs the main part of the operation specified in the name of the operation. Fraudulent applications will be punished. Surgeon and instructing assistant shall fill in the operation record. In principle, 2 surgeons cannot list their names in the surgeon column. Open table in a new tab Table 2Classification of procedures in the training for the Japanese Board of Cardiovascular Surgery (typical cases in categories A, B, and C)ABCCongenitalPDAASDPA bandingB-T shuntCoAVSDTOFFontanTGAValveTAPAortic valve replacementMitral valve replacementMitral valve plastyDouble valve surgeryCoronarySingle-vessel CABGMultiple-vessel CABGAortaReplacement of ascending aortaReplacement of abdominal aortaStent graftingReplacement of aortic archArteryThrombectomyPTAF-F bypassAxillo-femoral bypassFemoro-popliteal bypassDistal artery bypassVeinVarix surgeryVena cava surgeryOthersVascular accessTypical cases in categories A, B, and C are shown. Category A includes fundamental cases primarily performed by the first-year residents of cardiovascular surgery training. Category B includes routine cases typical for the second and third years of the residency. Category C represents the most advanced cases, usually performed by third-year residents or junior staff surgeons under appropriate supervision of senior staff surgeons. Complete lists of category A, B, and C cases are shown in Table E2. PDA, Patent ductus arteriosus; ASD, atrial septal defect; PA, pulmonary artery; B-T, Blalock–Taussig; CoA, coarctation of aorta; VSD, ventricular septal defect; TOF, tetralogy of Fallot; TGA, transposition of great arteries; TAP, tricuspid annuloplasty; CABG, coronary artery bypass grafting; PTA, percutaneous transluminal angioplasty; F-F, femoro-femoral. Open table in a new tab Table 3Requirements for board certification1.≥50 cases of cardiovascular surgery as a surgeon2.≥50 cases of cardiovascular surgery as the first surgeon3.≥3 attendances at annual surgical meetings including the JATS, JSCVS, JSVS, or JSS4.≥3 attendances in postgraduate courses sponsored by the JATS, JSCVS, JSVS, or JSS5.≥2 attendances in medical and patient safety courses sponsored by the JATS, JSCVS, JSVS, or JSS6.≥3 oral presentations at major national or international meetings7.≥3 publications in peer-reviewed journals in a relevant field including one as a primary author8.Minimum of 30 h off-the-job trainingJATS, Japanese Association for Thoracic Surgery; JSCVS, Japanese Society for Cardiovascular Surgry; JSVS, Japanese Society for Vascular Surgery; JSS, Japan Surgical Society. Open table in a new tab Operation score is as per table. The surgeon is the one who actually performs the main part of the operation specified in the name of the operation. Fraudulent applications will be punished. Surgeon and instructing assistant shall fill in the operation record. In principle, 2 surgeons cannot list their names in the surgeon column. Typical cases in categories A, B, and C are shown. Category A includes fundamental cases primarily performed by the first-year residents of cardiovascular surgery training. Category B includes routine cases typical for the second and third years of the residency. Category C represents the most advanced cases, usually performed by third-year residents or junior staff surgeons under appropriate supervision of senior staff surgeons. Complete lists of category A, B, and C cases are shown in Table E2. PDA, Patent ductus arteriosus; ASD, atrial septal defect; PA, pulmonary artery; B-T, Blalock–Taussig; CoA, coarctation of aorta; VSD, ventricular septal defect; TOF, tetralogy of Fallot; TGA, transposition of great arteries; TAP, tricuspid annuloplasty; CABG, coronary artery bypass grafting; PTA, percutaneous transluminal angioplasty; F-F, femoro-femoral. JATS, Japanese Association for Thoracic Surgery; JSCVS, Japanese Society for Cardiovascular Surgry; JSVS, Japanese Society for Vascular Surgery; JSS, Japan Surgical Society. Unlike the American Board of Thoracic Surgery (ABTS) board certification system, the JBCVS does not set limitations on the number of attempts. Instead, candidates who fail the exam work as nonindependent surgeons, and the length of the additional training period is primarily determined by program directors. A surgeon trained outside of Japan can apply for the board examination if the program director of his/her training institution provides a letter of certification indicating that the applicant has reached the surgical experience thresholds listed in Table 1, Table 2, Table 3. However, the applicant still needs to attend JATS, JSCVS, or JSVS meetings, be present at those meetings, and to participate in a postgraduate course, as well as in the patient safety courses listed in Table 3. Because our proposed training system only requires a Japanese medical license and completion of a 2-year internship, every candidate can apply for the JBCVS-certified training program even in the middle of his/her general surgery training period postgraduate year 3 to 5 for traditional training system (Figure 2). To recruit the best and brightest candidates from medical schools, the importance of reducing the training period while maintaining the quality of the training program was recognized. An integrated training system by overlapping general surgery and cardiovascular surgery training to lessen the total training period (Figure 2) was thus initiated in 2019. Candidates of new integrated cardiovascular training system are selected by the second year of (postgraduate year 2) their internship. The first graduates of the integrated training system will complete their training as early as 2022. To ensure optimal education, it is important to increase the number of required cases for accreditation of the training program, introduce detailed milestones that are easily understood by both surgical educators and residents, and establish an effective off-the-job training system that translates into better surgical techniques in the operating room. The Cardiovascular Surgery Training Program in Japan is divided into 2 categories based on the annual minimum number of cases (core training program: 100 cases; satellite training program: 50 cases) (Table E2). The program directors are required to maintain a high level of quality of training in each institution, which is accredited by the JBCVS. Other requirements for a qualified training program are listed in Table E2. As of August 2019, there were 422 core training programs and 120 satellite training programs. Definitions and requirements of core and satellite programs are shown in Table E2. Most cardiovascular surgery residents do not remain in 1 core hospital, but rather rotate through various core and satellite hospitals to gain experience in different types of surgery, including adult and congenital cardiac surgery, abdominal and peripheral vascular surgery, open and endovascular aortic surgery, transcatheter aortic valve replacement (TAVR), and mechanical circulatory support (Figure 3). Because of the rotation system, each resident is not assigned to 1 mentor. However, program directors of core and satellite programs regularly hold meetings and communicate effectively with one another to follow each resident's operative experience, technical proficiency, nontechnical skills, and academic productivity. Unlike the North American and European systems, there are no current limits on work hours. However, in 2023, work hours will be restricted by limiting the total hours of overtime work to 1860 hours per year. The total number of work hours per week will thus approximate the 80-hour restriction that exists in North America. The JBCVS has set criteria for the minimum surgical experience required before applying for board examination. Each cardiovascular procedure is classified into 1 of 3 categories (categories A, B, and C) depending on its difficulty and complexity (Tables 1, 2 and, E3). The range of cardiovascular procedures includes congenital, valvular, coronary, aorta, artery, vein, and intravascular procedures (Table E3). Although TAVR is ranked as a category B for TF approach and a category C for TA approach, rotation into a catheter laboratory is not mandatory in the current curriculum. Because more than 90% of TAVR cases are performed using the transfemoral approach and only a few cases are done using the transapical or transaortic approach, it is rare for cardiovascular surgeons to play a major role in TAVR procedures. The trainees can acquire points depending on their role in each procedure (Table 1). For example, a trainee who performs an aortic valve replacement as the operating surgeon is awarded 4 points. The trainees must earn a total of 500 points before applying for the JBCVS examination (Table 1, Table 2, Table 3). In addition, they must perform at least 50 procedures as the operating surgeon and at least 50 cases as the first assistant (Table 3). Attending surgeons and program directors make decisions as to whether a resident can register a case as “the surgeon” or the “first assistant.” Although the minimum required number of cases for JBCVS application is lower than that of the ABTS, there is a tremendous variety in the total number of cases. The median number of indexed cases as a primary surgeon of recent applicants was between 170 and 190 cases in the last 3 years. Of those, 70% of JBCVS applicants had 100 cases, 30% had more than 250 cases, and 12% had more than 500 cases. No trainees are allowed to operate independently before obtaining JBCVS board certification. Because young graduating surgeons who pass the JBCVS board may not be sufficiently qualified to perform complex cases as an independent surgeon when they first pass the board, they remain in their own program as clinical instructors or pursue a fellowship and accumulate further surgical experience under the direction of senior staff surgeons. The chief of a training program may hire them as assistant professors or junior partners or recommend them to other programs when they are ready to operate independently. In that way, quality of surgical outcomes in each program are maintained while junior staff surgeons gain enough experiences to confidently perform complex cases independently. Unlike the systems of the United States,12Brescia A.A. Lou X. Louis C. Blitzer D. Coyan G.N. Han J. et al.The thoracic surgery resident association: past contribution, current efforts, and future direction.J Thorac Cardiovasc Surg. August 31, 2020; ([Epub ahead of print])Abstract Full Text Full Text PDF Scopus (6) Google Scholar Canada,13Noly P.E. Rubens F.D. Ouozunian M. Quantz M. Shao-Hua W. Pelletier M. et al.Cardiovascular surgery training in Canada: current state and future perspectives.J Thorac Cardiovasc Surg. 2017; 154: 998-1005Abstract Full Text Full Text PDF PubMed Scopus (20) Google Scholar New Zealand, Australia,15Shi W.Y. Oldfield Z. Tam R. Cochrane A.D. Smith A.S. Cardiothoracic surgery training in Australia and New Zealand.J Thorac Cardiovasc Surg. 2018; 156: 718-725Abstract Full Text Full Text PDF PubMed Scopus (13) Google Scholar and other European countries,14Zakkar M. Benedetto U. Angelini G.D. Murphy G. Shah R. Jahangiri M. et al.Cardiothoracic surgery training in the United Kingdom.J Thorac Cardiovasc Surg. 2019; 157: 1948-1955Abstract Full Text Full Text PDF PubMed Scopus (9) Google Scholar,16Mennander A. Gudbjartason T. Jeppsson A. Hjortdal V. Tønnessen T. Specialist training for cardiothoracic surgery in the Nordic countries.J Thorac Cardiovasc Surg. 2020; 159: 1002-1008Abstract Full Text Full Text PDF PubMed Scopus (8) Google Scholar approximately 100% of young graduating surgeons stay in their programs or seek fellowships in other institutions and are paid by fixed salary. There are few private practice hospitals in Japan, and only a handful of senior surgeons work in such an environment. Although the majority of JBCVS board-certified surgeons stay in Japan, currently 40 Japanese surgeons work as attending physicians in the United States, 1 in Canada, and 5 in Germany. Requirements for JBCVS board certification renewal, which occurs every 5 years, are shown in Table E4. Currently, approximately 10% of cardiovascular surgeons cannot renew their certification because of an insufficient number of required surgical cases during the previous 5 years (Figure 4). The pyramidal structure of cardiovascular surgery practice in our country has changed over the last 5 years. The JBCVS has been encouraging senior surgeons to become teaching assistants by doubling the points for each teaching case. For example, if senior surgeons operate as the primary surgeon on a category C case, they earn 1 case, but if they assist on a category C case as a teaching assistant, they earn 2 cases. (Table 1). By doing so, senior surgeons can easily renew their board certification by participating in surgeries as teaching assistants. Trainees with previous procedural experience in cardiovascular surgery (ie, during their general surgery training) can receive points for those procedures to be applied toward their JBCVS application. Depending on the trainee's progress, the duration of the training may be extended (Figure 2). The JBCVS favors competence-based rather than time-based training; thus, trainees cannot apply for JBCVS certification until they fulfill all training requirements determined by the JBCVS (Table 1, Table 2, Table 3 and E3). Because there are no predetermined residency periods, some residents have to stay several more years to complete all the requirements before application. The JATS, JSCVS, and JSVS provide postgraduate seminars on topics ranging from basic surgical techniques in adult, congenital, and vascular surgery, to tips and pitfalls in advanced cardiovascular surgery. The trainees have to attend 3 postgraduate seminars by the end of their training (Table 3). These academic organizations also provide seminars on patient safety and professionalism at each annual meeting. The trainees must attend 2 of these seminars before applying for the JBCVS exam (Table 3). In 2017, the JBCVS announced that 30 hours of simulator-based skill training are mandatory to apply for board examination. The JATS, JSCVS, and JSVS provide several hands-on seminars using synthetic models or animal organs for coronary artery bypass grafting, aortic valve replacement, mitral valve replacement/repair, peripheral artery bypass, and stent grafting. In 2018, the JBCVS, with the support of the 3 academic societies (JSCVS, JATS, and JSVS), published a textbook focused on off-the-job training that describes techniques in simulator-based training and includes critical case scenarios and checklists for the trainee and surgeon-educator.17JATS JSCVS JSV Cardiovascular Surgery Off-The-Job Training Textbook. Nankodo, Tokyo, Japan2018Google Scholar In this textbook, off-the-job training is defined as supervised practice outside of the clinical setting, such as simulator-based skill training, critical case studies, and teamwork exercises using a simulated operating system.17JATS JSCVS JSV Cardiovascular Surgery Off-The-Job Training Textbook. Nankodo, Tokyo, Japan2018Google Scholar The reasons for increased simulator-based learning and out-of-operating room training include the following: (1) opportunities for trainees to be the operating surgeon have decreased because of increasing numbers of technically difficult, minimally invasive procedures, such as beating heart surgery, small-incision surgery, and endoscopic surgery; (2) because of economic realities, shortened operative times are preferable, and this reduces the amount of time that can be used to teach in the operating room; (3) there is growing social concern that it is ethically unacceptable to consider the operating room as a training space; and (4) there is pressure to shorten the total training period because the length of the current paradigm negatively affects the recruitment of the best and brightest medical students into cardiovascular surgery. The JBCVS defines goals for the knowledge, surgical skills, and mindset the trainees should aim for in each training stage (Table 4). Throughout their training period, all residents are required to regularly participate in mortality and morbidity conferences and discuss both attending surgeons' and their indexed cases. Each program holds teaching conferences and periodically has surgical rounds by invited guest speakers.Table 4Milestones of cardiovascular training for Japanese Board of Cardiovascular Surgery certificationI.First stage (1-2 y)1.To understand surgical anatomy, pathophysiology, and pathology, which are required in clinical practice for the treatment of cardiovascular diseases.2.To acquire knowledge of etiology, pathophysiology, and epidemiology, and learn methods for the diagnosis of cardiovascular diseases and be able to propose a treatment strategy for them.3.To gain the ability to manage patients with cardiovascular disease in an emergency situation.4.To perform perioperative management and basic surgical procedures including opening and closing the chest, cannulation for cardiopulmonary bypass, proper weaning from cardiopulmonary bypass, harvesting of saphenous vein grafts, closure of atrial septal defects, and peripheral vascular bypass surgery and cases listed in Category A.5.To perform team-based medical practice and consultation with a faculty member at the appropriate time.6.To attend scientific meetings related to cardiovascular surgery and present case reports at local cardiovascular meetings.II.Second stage (1-2 y)1.To perform more advanced surgical procedures including aortic valve replacement for aortic regurgitation, single coronary artery bypass or proximal anastomosis of CABG and other procedures listed in Category B.2.To obtain proper informed consent from patients and their representatives.3.To attend national scientific meetings related to cardiovascular surgery and present case reports or clinical studies at local or national meetings.III.Third stage (1-2 y)1.To perform surgical procedures, such as aortic valve replacement for severe aortic stenosis, simple CABG, and others listed in Categories B and C under the direction of surgical educators.2.Encouraged to perform collaborative research in a basic science department or research institution.3.Encouraged to participate in clinical research or clinical trials. Trainees are eligible for application to the JBCVS.CABG, Coronary artery bypass grafting; JBCVS, Japanese Board of Cardiovascular Surgery. Open table in a new tab CABG, Coronary artery bypass grafting; JBCVS, Japanese Board of Cardiovascular Surgery. Curriculum prepared by the JBCVS is not as detailed as that of the ABTS Cardiothoracic Surgery Training Milestones in the United States (Table 4). Nevertheless, the majority of institutions in Japan have a journal club and residents are required to present and discuss papers in each category of cardiovascular surgery. Moreover, all the residents are required to attend postgraduate courses offered at the JATS, JSCVS, and JSVS annual meetings, which is mandated by the JBCVS. Technical proficiency in the operating room is measured by attending surgeons and discussed with residents during debriefing conferences usually held the morning after a surgery. Near misses and unexpected events, as well as unplanned procedures, are shared with peer residents and other staff members. Detailed technical performance of junior residents is primarily evaluated by off-the-job training using simulators, while assessment of surgical performance of senior residents is shifted toward on-the-job training in the operating room without disturbing the flow of the surgery.18Bando K. Development of standardized evaluation methods for off-the-job training.J Jpn Surg Soc. 2019; 120: 534-542Google Scholar As a way to provide feedback to specialized training programs, the JBCVS and JCVSD monitor the training progress of the trainees annually and audits those institutions with suboptimal surgical outcomes, in which case clinical input by the JBCVS and JCVSD is required.19Yamamoto H. Miyata Y. Tanemoto K. Saiki Y. Yokoyama H. Fukuchi E. et al.Quality improvement in cardiovascular surgery: results of a surgical quality improvement programme using a nationwide clinical database and database-driven site visits in Japan.BMJ Qual Saf. 2020; 29: 560-568Crossref PubMed Scopus (3) Google Scholar The JBCVS and JCVSD provide guidance and support for quality improvements in the training system, as well as surgical results. In addition, trainers are required to learn methods for providing appropriate feedback to trainees at faculty development courses, usually held during the annual meetings of the JSS, and the 3 surgical societies (JATS, JSCVS, and JSVS) sponsored by the JBCVS. Program directors of core institutions are responsible for confirming that their trainees have officially fulfilled the required curriculum by assessing their knowledge of the surgical approach, pathophysiology, preoperative and postoperative patient care, proficiency in surgical procedures, off-the-job training experience, participation at annual meetings, and completion of postgraduate courses. Program directors also evaluate the trainees' nontechnical skills, which include leadership, professionalism, integrity, and teamwork. Although the requirements for board certification and renewal are well established, major challenges remain in developing an ideal cardiovascular surgical training system. First, similar to the certification procedure of the ABTS, candidates for JBCVS certification are required to complete a certain number of procedures in various areas with the program director's acknowledgment before taking a written examination. In other words, there is currently no objective (or less subjective) measure to assess the candidate's technical proficiency.18Bando K. Development of standardized evaluation methods for off-the-job training.J Jpn Surg Soc. 2019; 120: 534-542Google Scholar Thus, our assessment system lags those in other high-stakes professions, such as the aviation industry.20Sexton J.B. Thomas E.J. Helmreich R.L. Error, stress, and teamwork in medicine and aviation: cross sectional surveys.BMJ. 2000; 320: 745-749Crossref PubMed Scopus (4) Google Scholar Recently, we initiated a study to standardize the quality assessment of basic surgical techniques, including opening and closing the chest, harvesting the saphenous vein and internal thoracic artery, and instituting cardiopulmonary bypass, by reviewing video tapes of residents at various levels. However, we believe this approach is only an initial step toward establishing a technical assessment tool, and further standardized evaluation systems are necessary (Figure 5). The second challenge includes establishing a systematic and well-organized off-the-job training curriculum. Because the number of cases for each resident is limited, the role of off-the-job training is substantial. Of note, young members of the JSCVS have developed useful self-training tools for learning appropriate knot tying (Video 1), accurate handling of needle holders (Video 2), and safe cannulation of the ascending aorta (Video 3).17JATS JSCVS JSV Cardiovascular Surgery Off-The-Job Training Textbook. Nankodo, Tokyo, Japan2018Google Scholar To validate their efforts, an efficient curriculum system and a standardized evaluation system with appropriate feedback must be established (Figure 5).18Bando K. Development of standardized evaluation methods for off-the-job training.J Jpn Surg Soc. 2019; 120: 534-542Google Scholar The third challenge is that we currently do not have an efficient tool to measure the ability and quality of communication20Sexton J.B. Thomas E.J. Helmreich R.L. Error, stress, and teamwork in medicine and aviation: cross sectional surveys.BMJ. 2000; 320: 745-749Crossref PubMed Scopus (4) Google Scholar,21Roberts N.K. Williams R.G. Kim M.J. Dinnington G.L. The briefing, intraoperative teaching, debriefing model for teaching in the operating room.J Am Coll Surg. 2009; 208: 299-303Abstract Full Text Full Text PDF PubMed Scopus (151) Google Scholar among trainees and team members both inside and outside of operating rooms.18Bando K. Development of standardized evaluation methods for off-the-job training.J Jpn Surg Soc. 2019; 120: 534-542Google Scholar Previous tools, such as the Non-Technical Skills for Surgeons system,22Yule S. Flin R. Paterson-Brown S. Maran N. Non-technical skills for surgeons in the operating room: a review of the literature.Surgery. 2006; 139: 140-149Abstract Full Text Full Text PDF PubMed Scopus (492) Google Scholar are helpful and can be modified for assessment in cardiovascular surgery. Monitoring by video in the operating room and 360-degree evaluation by team members are possible, but these approaches require a high-level of commitment by the institution. Cardiovascular surgery training in Japan has been evolving to achieve the highest quality training of our residents. The JBCVS provides a rigorous process involving regular in-house off-the-job training, lectures on basic and advanced cardiovascular surgery, and nontechnical skills training. The combined efforts of the JBCVS and the JCVSD are effective and vitally important in monitoring the quality of surgical training in each institution. Further efforts are required to standardize the quality assessment of both the technical and nontechnical skills of trainees.

We report a 52-year-old man with primary cardiac angiosarcoma. He was referred to our hospital with a 3-month history of facial swelling and peripheral edema. Echocardiography and chest computed tomography revealed massive pericardial effusion and a right atrial tumor with a broad base at atrial septum which was extended into superior vena cava. We performed complete resection of the tumor and reconstruction of left atrium, atrial septum, right atrium, and superior vena cava with autologous pericardium and bovine pericardium. Histological examination exhibited angiosarcoma and a sign of radical excision. The patient, who made an uneventful recovery, was given postoperative radiotherapy and chemotherapy for liver metastasis 4 months postoperatively. The patient remains well without any signs of other metastasis for 2 years. We consider that an aggressive approach to resection with extensive reconstruction and multidisciplinary treatment can improve survival.

Recently, a study for eribulin mesylate(ERI), which is a useful drug for metastatic and recurrent breast cancer, reported that the absolute lymphocyte count(ALC)before administration is a useful prognostic factor. We retrospectively examined whether the results were reproducible in the patients with ERI. We examined the effect of ERI on the overall survival(OS)in 21 patients with HER2-negative metastatic and recurrent breast cancer who underwent treatment with ERI at our hospital. The clinical benefit ratio(CBR)was 57.1%. The median time to treatment failure(TTF)was 5.8 months and median OS was 19.9 months, showing a positive correlation between the TTF and OS. The factors that significantly prolonged the OS in univariate analysis were the TTF(<3 months vs ≥3 months, p<0.001), NLR(<3 vs ≥3, p=0.037), and ALC(<1,000/ μL vs ≥1,000/μL, p=0.008). In the multivariate analysis, TTF and ALC were the prognostic factors. The ERI outcome at our institution was good regardless of the subtype. The results of the multivariate analysis showed that TTF and ALC were factors that prolonged OS, and patients who received ERI for >3 months had good OS. Long-term administration of ERI was assumed to affect the immune microenvironment and prolong OS. Additionally, our data showed that the lymphocyte count before ERI administration is a simple and useful prognostic factor.

Central MessageA rapid strategy for initiating brain circulation is crucial to reduce ischemic brain insult for patients with cerebral malperfusion secondary to acute aortic dissection.See Article page 1713. A rapid strategy for initiating brain circulation is crucial to reduce ischemic brain insult for patients with cerebral malperfusion secondary to acute aortic dissection. See Article page 1713. In this issue of the Journal, Sultan and colleagues1Sultan I. Bianco V. Patel H.J. Arnaoutakis G.J. Eusanio M.D. Chen E.P. et al.Surgery for type A aortic dissection in patients with cerebral malperfusion: results from the International Registry of Acute Aortic Dissections.J Thorac Cardiovasc Surg. 2021; 161: 1713-1720.e1Scopus (15) Google Scholar present International Registry of Acute Aortic Dissection (IRAD) data for surgery for acute thoracic aortic dissection in patients who had neurologic deficits before surgery. The authors defined cerebral malperfusion (CM) as when the neurologic deficit was detected preoperatively. CM is usually defined as poor cerebral perfusion due to severe stenosis or occlusion of the branches of the aortic arch due to the extension of the dissection or expansion of the false lumen. Patients with impaired consciousness are unable to complain of the typical pain of aortic dissection, so the following strange results are described in this paper. “Patients with CM were less likely to present with chest pain and back pain. CM patients were more likely to present with syncope, peripheral malperfusion, and in shock.” In this paper, there was no classification of neurologic deficit as a coma or syncope or limb paralysis. The proportion of patients with coma was unknown. There may be a significant number of cases that were not eligible for surgery due to coma status. Since these nonsurgical patients were not registered in IRAD, selection bias was considered to be significant for surgical indications. Those points illustrate some limitations of this paper, as the authors have described. Analyzes were made on surgical mortality, but there is no analysis of sustained or recovered brain function after surgery. It is difficult to determine the malperfusion of 3 branches of the aortic arch due to aortic dissection without image findings, but the IRAD lacked image finding data. Therefore, defining neurologic deficits by physical examination as CM is a weakness of this paper. From the image findings, it is possible to judge the dissection of the arch branches and the degree of stenosis or occlusion. Furthermore, the region of malperfusion and degree of ischemia vary depending on the state of the circle of Willis. The surgical strategy should be selected based on these image findings.2Okita Y. Ikeno Y. Yokawa K. Henmi S. Gotake Y. Nakai H. et al.Direct perfusion of the carotid artery in patients with brain malperfusion secondary to acute aortic dissection.Gen Thorac Cardiovasc Surg. 2019; 67: 161-167Crossref PubMed Scopus (14) Google Scholar, 3Furukawa T. Uchida N. Takahashi S. Yamane Y. Mochizuki S. Yamada K. et al.Management of cerebral malperfusion in surgical repair of acute type A aortic dissection.Eur J Cardiothorac Surg. 2017; 52: 327-332Crossref PubMed Scopus (14) Google Scholar, 4Tsukube T. Hayashi T. Kawahira T. Haraguchi T. Matsukawa R. Kozawa S. et al.Neurological outcomes after immediate aortic repair for acute type A aortic dissection complicated by coma.Circulation. 2011; 124: S163-S167Crossref PubMed Scopus (52) Google Scholar The cases transferred to the secondary and tertiary medical centers are in a relatively stable state that can withstand transportation, and the details of acute type A aortic dissection have been diagnosed based on computed tomography and ultrasound findings. IRAD's participating facilities are tertiary hospitals and show the results of these selected patients. The survival rate of 75% is likely to be different from the real world. In any case, the conclusions of this paper are valuable in recommending rapid surgical treatment. Several reference papers defined CM based on image findings of occlusion or a high degree of stenosis in branches of the aortic arch. These papers also described the use of various treatment strategies aimed at the probability of cerebral perfusion from the viewpoint of brain protection, such as rapid initiation of extracorporeal circulation using carotid artery or right axillary artery cannulation.2Okita Y. Ikeno Y. Yokawa K. Henmi S. Gotake Y. Nakai H. et al.Direct perfusion of the carotid artery in patients with brain malperfusion secondary to acute aortic dissection.Gen Thorac Cardiovasc Surg. 2019; 67: 161-167Crossref PubMed Scopus (14) Google Scholar, 3Furukawa T. Uchida N. Takahashi S. Yamane Y. Mochizuki S. Yamada K. et al.Management of cerebral malperfusion in surgical repair of acute type A aortic dissection.Eur J Cardiothorac Surg. 2017; 52: 327-332Crossref PubMed Scopus (14) Google Scholar, 4Tsukube T. Hayashi T. Kawahira T. Haraguchi T. Matsukawa R. Kozawa S. et al.Neurological outcomes after immediate aortic repair for acute type A aortic dissection complicated by coma.Circulation. 2011; 124: S163-S167Crossref PubMed Scopus (52) Google Scholar In the future, we should clarify the criteria for surgical indications for patients with severe coma due to CM. Surgery for type A aortic dissection in patients with cerebral malperfusion: Results from the International Registry of Acute Aortic DissectionThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 5PreviewThe strategy for intervention remains controversial for patients presenting with type A aortic dissection (TAAAD) and cerebral malperfusion with neurologic deficit. Full-Text PDF

Haemorrhage during and following surgery results in increased morbidity and mortality. Low plasma fibrinogen levels have been associated with increased blood loss and transfusion requirements. Fibrinogen supplementation has been shown to reduce bleeding in coagulopathic patients. This post hoc study evaluated fibrinogen repletion and pharmacokinetic data from the REPLACE study. One hundred and fifty-two adult patients undergoing elective aortic surgery requiring cardiopulmonary bypass (CPB) with defined bleeding of 60-250 g at first 5 min bleeding mass were included in the phase III trial. Patients were randomized to receive either fibrinogen concentrate (FCH) or placebo following CPB removal. Plasma fibrinogen levels and viscoelastic testing parameters (ROTEM-based FIBTEM and EXTEM assays) were measured before, during, and after study treatment administration. A mean dose of 6.3 g FCH was administered in the FCH group, with a median infusion duration of 2 min. Immediately following completion of FCH administration, a rapid increase in plasma fibrinogen levels to near baseline (median change from baseline -0.10 g/l) was seen in the FCH group but not in the placebo group (median change from baseline -1.29 g/l). FCH administration also caused an immediate increase in FIBTEM maximum clot firmness (MCF) to 23 mm and improvements in EXTEM coagulation time and clot formation time by the end of infusion. There was a strong correlation between the plasma fibrinogen level and FIBTEM MCF. Treatment with high doses of FCH with a rapid infusion time resulted in immediate recovery to baseline levels of plasma fibrinogen and viscoelastic testing parameters.

Cardiac blood cyst in adults is a rare benign tumor. Cardiac blood cyst concomitant with another type of cardiac tumor has never been reported. We report a case of a 77-year-old woman with cardiac blood cyst and papillary fibroelastoma. We performed resection of both tumors. An encapsulated mass (15 mm in diameter) with short stalks was identified in the right atrium, and a soft 1-cm mass was found adhering to a large part of the aortic valve noncoronary cusp without stalks. Postoperative course was uneventful. .

Central MessageAn algorithmic approach to acute aortic emergencies during the COVID-19 pandemic can reduce the risk of exposure for patients and health care providers.See Commentaries on pages 54 and 55. An algorithmic approach to acute aortic emergencies during the COVID-19 pandemic can reduce the risk of exposure for patients and health care providers. See Commentaries on pages 54 and 55. The coronavirus disease 2019 (COVID-19) pandemic has placed an unprecedented strain on hospitals worldwide, necessitating health care systems to triage patient care and redirect resources including personnel, equipment, and operating rooms. Aortic emergencies, including aortic dissection, rupture, and malperfusion syndromes, are resource-intensive and therefore can overwhelm a system already operating at maximal capacity. Although health care systems are necessarily shifting resources to address the COVID-19 pandemic, a contingency plan to continue to support aortic emergencies needs to remain in place. This document is meant to facilitate triage and management of these acute patients based on the best-available evidence.1.How should hospitals manage COVID-19–positive or status unknown patients who present to their hospital with an aortic emergency?a.Patients who present to an emergency department (ED) with an aortic emergency should initially be triaged into 1 of 3 categories based on their COVID-19 status by testing. A flowchart for triaging patients is demonstrated in Figure 1.i.COVID-19–negative: Patients who have tested negative for COVID-19 should be managed by transfer to a routine surgical operating room (OR) and routine surgical intensive care unit (ICU) postoperatively.1.Patients who test negative but have concerning signs/symptoms and/or radiologic findings concerning for infection on computed tomography scan (ie, possible false-negative; see Figure 2) should be treated as COVID-19 status unknown with full COVID-19 personal protective equipment (PPE) precautions and potentially retested using rapid testing.ii.COVID-19–positive: Patients who have tested positive for COVID-19 should be managed with full PPE precautions and should be taken to a COVID-19–designated OR (capable of negative-pressure airflow) and subsequently to a COVID-19–designated ICU with close surgical team consultation.1.Consider early intubation for symptomatic patients, ensuring appropriate PPE and in a negative pressure airflow room if able.iii.COVID-19 status unknown: Patients for whom testing status is unknown or indeterminate should be handled with full PPE precautions and tested by rapid test in the ED.1.Consider early intubation for symptomatic patients, ensuring appropriate PPE and in a negative-pressure airflow room if able.2.If a sample needs to be obtained after intubation, consider tracheal aspirate or bronchoalveolar lavage, which have greater sensitivity than a nasopharyngeal swab, in accordance with the Society of Critical Care Medicine recommendations.1Alhazzani W. Moller M.H. Arabi Y.M. Loeb M. Gong M.N. Fan E. et al.Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19).Crit Care Med. 2020; 46: 854-887Google Scholar3.Patients should be taken to a COVID-19–designated ICU postoperatively until testing returns. If testing is negative, the patient should be transferred to a routine surgical ICU.Figure 1Algorithm for triaging patients from the emergency room based on COVID testing status. ∗Patients requiring high flow oxygen, non-invasive ventilation, or other oxygen source with high potential for aerosol-generation should be considered for early intubation in the ER in order to reduce viral spread during transport. ED, Emergency department; COVID-19, coronavirus disease 2019; CT, computed tomography; PPE, personal protective equipment; OR, operating room; NP, nasopharyngeal; BAL, bronchoalveolar lavage; ICU, intensive care unit.View Large Image Figure ViewerDownload Hi-res image Download (PPT)2.How should hospitals manage interfacility transfers of COVID-19–positive or status unknown patients?a.The transfer of care to a greater level of care centers capable of handling aortic emergencies should continue during the COVID-19 pandemic but is necessarily dictated by local protocols. A flowchart for triaging patients from an external hospital is provided in Figure 3.Figure 3Algorithm for triaging patients from an external hospital. ∗Patients requiring high-flow oxygen, noninvasive ventilation, or other oxygen source with high potential for aerosol-generation should be considered for early intubation before transport to reduce viral spread during transport. COVID-19, Coronavirus disease 2019; CT, computed tomography; PPE, personal protective equipment; EMS, emergency medical services; OR, operating room; NP, nasopharyngeal; BAL, bronchoalveolar lavage; ICU, intensive care unit.View Large Image Figure ViewerDownload Hi-res image Download (PPT)b.Patient transfer centers should alert the receiving treatment team of the patient's COVID-19 infection status. If the COVID-19 status is unknown, rapid testing, if available, should be performed by the transferring hospital before transport to the receiving facility.c.Hospitals that have direct-to-OR transfer protocols for emergencies should continue to follow strict safety precautions to decrease the risk of transmission, and ensure the following:i.Confirm transfer hospitals provide all pertinent medical records and imaging disks to decrease need for unnecessary repeat imaging testing at receiving facility.ii.Limit family members from entering the receiving facility and establishing clear health care power of attorney contact information for decision-making.d.Emergency medical services (EMS) and other transport personnel should wear appropriate recommended PPE (N95 or higher-level respirator or facemask when respirator unavailable, gloves, gown, eye protection)2Interim Guidance for Emergency Medical Services (EMS) Systems and 911 Public Safety Answering Points (PSAPs) for COVID-19 in the United States.https://www.cdc.gov/coronavirus/2019-ncov/hcp/guidance-for-ems.htmlDate: 2020Date accessed: April 25, 2020Google Scholar and take the following precautions:i.Limit the number of personnel involved in the care and transfer of the patient.ii.Minimize the spread of aerosol-generating equipment and procedures.iii.Avoid transportation of the patient requiring high-flow oxygen (>15 L/min) or noninvasive ventilation, such as bi-level positive airway pressure or continuous positive airway pressure. Early intubation before transport should be considered for patients requiring-high flow oxygen (>15 L/min) or noninvasive ventilation.3Odor P.M. Neun M. Bampoe S. Clark S. Heaton D. Hoogenboom E.M. et al.Anaesthesia and COVID-19: infection control.Br J Anaesth. 2020; 125: 16-24Abstract Full Text Full Text PDF PubMed Scopus (86) Google Scholariv.Patients may be transported on low-flow oxygen sources (such as nasal cannula, simple facemask, or non-rebreather mask). Face masks should be worn by the patient, including over any airway devices.v.Have a clearly designated route to the patient transfer area; the receiving facility should have a representative available to escort the transport personnel to avoid unnecessary travel around the hospital.3.What preoperative considerations should be taken to minimize risk to health care personnel for COVID-19–positive or status unknown patients?a.For surgical emergencies going directly to the OR, consider performing patient preoperative evaluation and any necessary procedures in the ED before transport to the OR (Table 1).i.Provide bundled care treatment (blood draws, electrocardiogram evaluation, consent, and surgical-site marking) to minimize personnel movement into and out of the room.b.Hospitals that have direct-to-OR transfer protocols for emergencies should identify a preoperative surgical staging area where care can be transferred from EMS personnel to hospital personnel.i.A surgical staging area may be a preoperative setting for centers with direct-to-OR abilities, or an ICU, depending on local protocols.ii.EMS personnel should not transport patients directly to the OR, if possible, to avoid contamination.c.Appropriate PPE measures include the following:i.Airway team: N95 masks or appropriate respirator, eye protection, gown, gloves, and head cover. A powered air-purifying respirator can also be considered when available.ii.Nursing and surgical teams: N95 masks or appropriate respirator, eye protection, gown, gloves, and head cover.d.Surgical procedures should ideally be performed in COVID-19–designated ORs that have the capability of providing negative-pressure airflow. Doffing of PPE should be performed adjacent to the OR doorway before leaving the room, or in a separate anteroom if available.e.The minimum number of personnel required should be directly involved in patient care to reduce exposure. Team members at greater risk of COVID-19 infection should be identified and accommodated.f.If the patient goes into cardiac arrest before procedure, standard advanced cardiovascular life support guidelines should be performed with the following modifications4Edelson D.P. Sasson C. Chan P.S. Atkins D.L. Aziz K. Becker L.B. et al.Interim guidance for basic and advanced life Support in adults, children, and neonates with suspected or confirmed COVID-19: from the emergency cardiovascular care committee and get with the guidelines((R))-resuscitation adult and pediatric task forces of the American Heart Association in collaboration with the American Academy of Pediatrics, American Association for Respiratory Care, American College of Emergency Physicians, The Society of Critical Care Anesthesiologists, and American Society of Anesthesiologists: supporting organizations: American Association of Critical Care Nurses and National EMS Physicians.Circulation. 2020; 141: e933-3Google Scholar:i.Chest compressions should be held during airway procedures to reduce aerosol generation and protect airway personnel.ii.The minimal required personnel should be directly involved in patient care with a runner nearby to retrieve equipment and medications.iii.In the event of suspected aortic catastrophe, early termination of resuscitative efforts should be considered.g.Medical therapy and palliation are reasonable alternatives, particularly in patients with symptomatic COVID-19 infection.5Trimarchi S. Eagle K.A. Nienaber C.A. Rampoldi V. Jonker F.H.W. De Vincentiis C. et al.Role of age in acute type A aortic dissection outcome: report from the international registry of acute aortic dissection (IRAD).J Thorac Cardiovasc Surg. 2010; 140: 784-789Abstract Full Text Full Text PDF PubMed Scopus (239) Google Scholar4.What are the important anesthetic considerations for COVID-19–positive and status unknown patients?a.All precautions should be taken to minimize exposure to aerosol-generating procedures in the OR. Staff not involved in the management of the airway should wait outside the OR during this time.b.In accordance with the World Health Organization and Centers for Disease Control and Prevention, aerosol-generating procedures should be performed in a negative-pressure airflow room.c.Recommendations for endotracheal intubation include rapid sequence intubation, intubation performed by a highly experienced and efficient provider, and elective use of a video laryngoscope if available.1Alhazzani W. Moller M.H. Arabi Y.M. Loeb M. Gong M.N. Fan E. et al.Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19).Crit Care Med. 2020; 46: 854-887Google Scholar,6Orser B.A. Recommendations for endotracheal intubation of COVID-19 patients.Anesth Analg. 2020; 130: 1109-1110Crossref PubMed Scopus (143) Google Scholari.Video laryngoscope allows the provider's face to be further away from the patient during intubation.7Meng L. Qiu H. Wan L. Ai Y. Xue Z. Guo Q. et al.Intubation and ventilation amid the COVID-19 outbreak: Wuhan's experience.Anesthesiology. 2020; 132: 1317-1332Crossref PubMed Scopus (400) Google Scholar In addition, a video laryngoscope may be beneficial in decreasing failed intubation attempts8Lewis S.R. Butler A.R. Parker J. Cook T.M. Schofield-Robinson O.J. Smith A.F. Videolaryngoscopy versus direct laryngoscopy for adult patients requiring tracheal intubation: a cochrane systematic review.Br J Anaesth. 2017; 119: 369-383Abstract Full Text Full Text PDF PubMed Scopus (216) Google Scholar and increasing the success rate.ii.The use of a high-efficiency hydrophobic filter should be interposed between the endotracheal tube and resuscitation bag or anesthesia circuit.iii.Care should be taken to avoid contamination or cross-contamination after intubation.d.If testing for COVID-19 was not yet achieved, a sample should be collected once in the OR.i.The nasopharyngeal swab may be obtained; however, concerns have been expressed over the sensitivity of this sample.9Xie C. Jiang L. Huang G. Pu H. Gong B. Lin H. et al.Comparison of different samples for 2019 novel coronavirus detection by nucleic acid amplification tests.Int J Infect Dis. 2020; 93: 264-267Abstract Full Text Full Text PDF PubMed Scopus (243) Google Scholar When the patient is intubated in the OR, a lower respiratory tract sample should be considered, in the form of a tracheal aspirate or bronchial alveolar lavage, in accordance with recommendations from the Society of Critical Care Medicine.1Alhazzani W. Moller M.H. Arabi Y.M. Loeb M. Gong M.N. Fan E. et al.Surviving sepsis campaign: guidelines on the management of critically ill adults with coronavirus disease 2019 (COVID-19).Crit Care Med. 2020; 46: 854-887Google Scholare.Ventilation of patients during the procedure should consider the pulmonary effects of patients infected with COVID-19.i.Infected patients may present with acute respiratory distress syndrome (ARDS); however, some patients may have mild hypoxemia or be asymptomatic carriers.1.Low tidal volume mechanical ventilation should be used to prevent further lung injury, as indicated in other types of ARDS.10Brower R.G. Lanken P.N. MacIntyre N. Matthay M.A. Morris A. Ancukiewicz M. et al.Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.N Engl J Med. 2004; 351: 327-336Crossref PubMed Scopus (1934) Google Scholar,11Fan E. Del Sorbo L. Goligher E.C. Hodgson C.L. Munshi L. Walkey A.J. et al.An official American Thoracic Society/European Society of Intensive Care Medicine/Society of Critical Care Medicine clinical practice guideline: mechanical ventilation in adult patients with acute respiratory distress syndrome.Am J Respir Crit Care Med. 2017; 195: 1253-1263Crossref PubMed Scopus (900) Google Scholar2.It is also reasonable to consider higher positive end-expiratory pressure as needed for hypoxemia per evidence-based ARDS protocols.10Brower R.G. Lanken P.N. MacIntyre N. Matthay M.A. Morris A. Ancukiewicz M. et al.Higher versus lower positive end-expiratory pressures in patients with the acute respiratory distress syndrome.N Engl J Med. 2004; 351: 327-336Crossref PubMed Scopus (1934) Google Scholar,12Mercat A. Richard J.C. Vielle B. Jaber S. Osman D. Diehl J.-L. et al.Positive end-expiratory pressure setting in adults with acute lung injury and acute respiratory distress syndrome: a randomized controlled trial.JAMA. 2008; 299: 646-655Crossref PubMed Scopus (1049) Google Scholarf.The risk of performing an intraoperative transesophageal echocardiogram (TEE) in patients infected with COVID-19 is high.i.Per the American Society of Echocardiography, the benefit of performing a TEE may outweigh the risk in a type A dissection in a COVID-19–positive or suspected patient.13Nicoara A.M. Maldonado Y. Kort S. Swaminathan M. Mackensen G.B. Specific considerations for the protection of patients and echocardiography service providers when performing perioperative or periprocedural transesophageal echocardiography during the 2019 novel coronavirus outbreak: council on perioperative echocardiography supplement to the statement of the American Society of Echocardiography.J Am Soc Echocardiogr. 2020; 33: 666-669Abstract Full Text Full Text PDF PubMed Scopus (26) Google Scholar A case-by-case basis should be considered when determining whether to perform a TEE.ii.Care should be taken to minimize contamination of surfaces while performing a TEE and appropriate PPE donned during the procedure.5.What precautions should be taken by surgical personnel during the procedure?a.Expeditious repairs requiring minimal operating and cardiopulmonary bypass times should be favored over complex operations. The priorities should be to safely address any life-threatening issues, to be efficient with resource use, and to minimize the risk of postoperative complications.14Waterford S.D. Gardner R.L. Moon M.R. Extent of aortic replacement in Type A dissection: current answers for an endless debate.Ann Thorac Surg. 2018; 106: 1246-1250Abstract Full Text Full Text PDF PubMed Scopus (17) Google Scholari.Endovascular options (if available and applicable to the clinical scenario) should be considered over open surgical procedures when possible.b.Prepping and draping the patient should be done in usual sterile fashion, with emphasis on providing an appropriate drape barrier between anesthesia and surgical teams to minimize surgical personnel exposure to airway and TEE interventions.c.Observing, nonessential personnel should not be present during the procedure to reduce the amount of personnel in close contact.d.During the COVID-19 pandemic, there have been concerns over adequate blood supply for patients in some regions due to increased blood product use and blood donation shortages. Blood-conservation management should be used during surgical procedures for aortic emergencies. The following measures should be considered where available:i.intraoperative cell salvage15Carless P.A. Henry D.A. Moxey A.J. O'Connell D. Brown T. Fergusson D.A. Cell salvage for minimising perioperative allogeneic blood transfusion.Cochrane Database Syst Rev. 2010; : CD001888Google Scholar;ii.modified ultrafiltration16Torina A.G. Silveira-Filho L.M. Vilarinho K.A. Eghtesady P. Oliveira P.P.M. Sposito A.C. et al.Use of modified ultrafiltration in adults undergoing coronary artery bypass grafting is associated with inflammatory modulation and less postoperative blood loss: a randomized and controlled study.J Thorac Cardiovasc Surg. 2012; 144: 663-670Abstract Full Text Full Text PDF PubMed Scopus (31) Google Scholar;iii.acute normovolemic hemodilution17Barile L. Fominskiy E. Di Tomasso N. Alpìzar Castro L.E. Landoni G. De Luca M. et al.Acute normovolemic hemodilution reduces allogeneic red blood cell transfusion in cardiac surgery: a systematic review and meta-analysis of randomized trials.Anesth Analg. 2017; 124: 743-752Crossref PubMed Scopus (118) Google Scholar;iv.viscoelastography-guided transfusions18Kuiper G. van Egmond L.T. Henskens Y.M.C. Roekaerts P.M. Maessen J.G. Ten Cate H. et al.Shifts of transfusion demand in cardiac surgery after implementation of rotational thromboelastometry-guided transfusion protocols: analysis of the HEROES-CS (HEmostasis Registry of patiEntS in Cardiac Surgery) observational, prospective open cohort database.J Cardiothorac Vasc Anesth. 2019; 33: 307-317Abstract Full Text Full Text PDF PubMed Scopus (37) Google Scholar; andv.ensuring good hemostasis to minimize blood product use and need to return to OR.e.Chest tubes should be checked for air leaks and ensuring that all connections are secure to reduce exposure via contamination.19Bilkhu R. Viviano A. Saftic I. Billè A. COVID-19: Chest Drains With Air Leak—The Silent 'Super Spreader'?.https://doi.org/10.25373/ctsnet.12089130.v1Date: 2020Date accessed: May 14, 2020Google Scholar6.What are the postoperative considerations for COVID-19–positive and status-unknown patients?a.Patients should ideally be transported to a COVID-19–designated ICU with close consultation with the surgical team, unless hospital protocols dictate otherwise.b.Timing and planning for extubation will be multifactorial, and attention should be given to the patient's hemodynamic stability, neurologic examination, respiratory status, and any postsurgical concerns.i.Since extubation is also an aerosol-generating procedure, extubation should be performed in a negative-pressure airflow room with appropriate PPE and minimizing personnel in the room at time of extubation.ii.Meticulous care should be given to ensure patients are adequately ready for extubation to minimize risk of reintubation.c.Patients in whom COVID-status was initially unknown but later returns as negative should be moved to a routine surgical ICU setting.Table 1Suggested approach for the management of aortic emergencies during the COVID-19 pandemicPreoperative considerationsPreoperative evaluation should be performed before transport to ORA preoperative surgical staging area should be identified (for direct-to-OR protocols)Appropriate PPE measures should be strictly followed for all personnelSurgical procedures should ideally be performed in COVID-19–designated ORs that have the capability of providing negative pressure airflowThe minimum number of personnel required should be directly involved in patient careAnesthetic considerationsAll precautions should be taken to minimize exposure to aerosol-generating proceduresRecommendations for endotracheal intubation include rapid sequence intubation, an experienced provider performing the procedure, and elective use of a video laryngoscopeIf testing for COVID-19 was not yet achieved, a sample should be collected once in the operating roomVentilation of patients should follow ARDS protocolsCare should be taken during TEE examination, including appropriate PPEProcedural considerationsPrepping and draping in usual sterile fashion with emphasis on an appropriate drape barrier between anesthesia and surgical teamsExpeditious repairs should be favored over complex repairsConsider blood-conservation management strategiesChest tubes should be checked for air leaks and secure connectionsPostoperative careIdeal postoperative care in a COVID-19–designated ICUExtubation criteria should be carefully considered to mitigate risk of reintubationOR, Operating room; COVID-19, coronavirus 2019; ARDS, acute respiratory distress syndrome; TEE, transesophageal echocardiogram; PPE, personal protective equipment; ICU, intensive care unit. Open table in a new tab OR, Operating room; COVID-19, coronavirus 2019; ARDS, acute respiratory distress syndrome; TEE, transesophageal echocardiogram; PPE, personal protective equipment; ICU, intensive care unit. Dr Malaisrie: Terumo, Cryolife, and Medtronic; Dr Fleischmnan: Terumo, Edwards Lifesciences, W. L. Gore, and Cook; Dr Bavaria: Terumo, W. L. Gore, Medtronic, and Cook Vascular; Dr Moon: Medtronic. All other authors reported no conflicts of interest. The Journal policy requires editors and reviewers to disclose conflicts of interest and to decline handling or reviewing manuscripts for which they may have a conflict of interest. The editors and reviewers of this article have no conflicts of interest. Commentary: Managing thoracic aortic emergencies during a pandemicThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 1PreviewThe coronavirus 2019 (COVID-19) pandemic continues to burden the health care infrastructure with unprecedented challenges. Management of acute aortic emergencies during a pandemic increases the complexity of an already resource-heavy disease. Full-Text PDF Open ArchiveCommentary: Fool me once, shame on you, fool me twice, shame on me—preparing for acute aortic emergencies and the next wave of the COVID-19 pandemicThe Journal of Thoracic and Cardiovascular SurgeryVol. 161Issue 1PreviewThe coronavirus disease 2019 (COVID-19) pandemic has completely altered the healthcare landscape within a very short period owing to the rapid influx of patients requiring medical attention related to the severe acute respiratory syndrome coronavirus 2 infection displacing patients needing other types of medical attention. Entire hospital systems were restructured to accommodate the intensive needs of patients with COVID-19, and hospital capacity was quickly overwhelmed in terms of actual space and the necessary personnel. Full-Text PDF Open Archive

Differences in vocal tract lengths (VTLs) in individual speakers cause variations in acoustic features of phonemes. In this paper, a simple method to estimate speaker-specific VTLs and to quantitatively evaluate some speaker-normalization effects of the VTLs is proposed. We employed accumulated means of formant trajectories to estimate the VTLs of speakers ranging from children to adults. For the formant estimation, the inverse-filter control (IFC) system was used. In the system, the decision of analysis order, which means number of formants to be estimated, is automated. Moreover, to evaluate the speaker-normalization effect of VTLs, we proposed the data reduction method, which can reasonably find dense areas of ellipses from distributions in the formant space. Using these ellipse areas, we evaluated the three normalization effects of VTLs: normalization by the mean of all VTLs as the standard, by speaker-categorical means of VTLs, and by individual VTLs. The area reduced from the standard area of the original data by 39.5% and 46.6% in the case of the categorical means and individual VTLs, respectively. As a result, our proposed method was used to provide a “normalized vowel map (NVM)” that visualizes universal vowel-distributions as a core image of linguistic information. Finally, we compared the estimated VTLs with those by another method based on magnetic resonance imaging (MRI) data, using the proposed methods.

Background In 2015, an academic-led surgical quality improvement (QI) programme was initiated in Japan to use database information entered from 2013 to 2014 to identify institutions needing improvement, to which cardiovascular surgery experts were sent for site visits. Here, posthoc analyses were used to estimate the effectiveness of the QI programme in reducing surgical mortality (30-day and in-hospital mortality). Methods Patients were selected from the Japan Cardiovascular Surgery Database, which includes almost all cardiovascular surgeries in Japan, if they underwent isolated coronary artery bypass graft (CABG), valve or thoracic aortic surgery from 2013 to 2016. Difference-in-difference methods based on a generalised estimating equation logistic regression model were used for pre-post comparison after adjustment for patient-level expected surgical mortality. Results In total, 238 778 patients (10 172 deaths) from 590 hospitals, including 3556 patients seen at 10 hospitals with site visits, were included from January 2013 to December 2016. Preprogramme, the crude surgical mortality for site visit and non-site visit institutions was 9.0% and 2.7%, respectively, for CABG surgery, 10.7% and 4.0%, respectively, for valve surgery and 20.7% and 7.5%, respectively, for aortic surgery. Postprogramme, moderate improvement was observed at site visit hospitals (3.6%, 9.6% and 18.8%, respectively). A difference-in-difference estimator showed significant improvement in CABG (0.29 (95% CI 0.15 to 0.54), p<0.001) and valve surgery (0.74 (0.55 to 1.00); p=0.047). Improvement was observed within 1 year for CABG surgery but was delayed for valve and aortic surgery. During the programme, institutions did not refrain from surgery. Conclusions Combining traditional site visits with modern database methodologies effectively improved surgical mortality in Japan. These universal methods could be applied via a similar approach to contribute to achieving QI in surgery for many other procedures worldwide.

Background: Despite recent advances in the diagnosis and management, the mortality of acute aortic dissection remains high. This study aims to clarify the current status of the management and outcome of acute aortic dissection in Japan. Methods: A total of 18,348 patients with acute aortic dissection (type A: 10,131, type B: 8217) in the Japanese Registry of All Cardiac and Vascular Diseases database between April 2012–March 2015 were studied. Characteristics, clinical presentation, management, and in-hospital outcomes were analyzed. Results: Seasonal onset variation (autumn- and winter-dominant) was found in both types. More than 90% of patients underwent computed tomography for primary diagnosis. The overall in-hospital mortality of types A and B was 24.3% and 4.5%, respectively. The mortality in type A patients managed surgically was significantly lower than in those not receiving surgery (11.8% (799/6788) vs 49.7% (1663/3343); p<0.001). The number of cases managed endovascularly in type B increased 2.2-fold during the period, and although not statistically significant, the mortality gradually decreased (5.2% to 4.1%, p=0.49). Type A showed significantly longer length of hospitalization (median 28 days) and more than five times higher medical costs (6.26 million Japanese yen) than those in type B. The mean Barthel index at discharge was favorable in both type A (89.0±22.6) and type B (92.6±19.0). More than two-thirds of type A patients and nearly 90% of type B patients were directly discharged home. Conclusions: This nationwide study elucidated the clinical features and outcomes in contemporary patients with acute aortic dissections in real-world clinical practice in Japan.

症例は77歳の女性．60歳代より非弁膜症性心房細動（non valvular atrial fibrillation ; NVAF）に対してワルファリンで抗凝固療法を施行されていた．1年半前に心原性脳塞栓症を発症しダビガトラン300 mg/日の内服を開始した．しかし，3カ月前に脳塞栓症を発症した．退院後のMRIにてさらに新規の脳塞栓症発症を認めた．超音波検査および造影CTを施行し，左房内に37×29 mm大の遊離した血栓を認めたため，緊急手術を施行した．左房内の血栓摘出術および左心耳閉鎖術を行った．術後はワルファリンによる抗凝固療法を行い，再発なく経過している．ダビガトラン内服中にもかかわらず左房内巨大血栓による多発塞栓症を発症した1例を経験したので報告する．

OBJECTIVES:The mortality of acute aortic dissection (AAD) remains high, and evidence-to-practice gaps exist in real-world treatment. We explored the first quality indicators (QIs) for AAD management and evaluated the associations between the achievement of these QIs and the outcome in a nationwide administrative database. METHODS:A systematic search was performed to establish initial index items for QIs. An evaluation was performed through an expert consensus meeting using the Delphi method. We studied 18 348 patients who had AAD (type A: 10 131; type B: 8217) in the Japanese Registry of All Cardiac and Vascular Diseases database between April 2012 and May 2015. The associations between the achievement of QIs [categorized into tertiles (low, middle and high)] and in-hospital mortality were determined by multivariable mixed logistic regression analyses. RESULTS AND CONCLUSION:We developed a total of 9 QIs (5 structural and 4 process). Lower achievement rates of QIs were significantly associated with higher in-hospital mortality in both types [type A = middle: odds ratio (OR) 4.03; 95% confidence interval (CI) 3.301-4.90; P < 0.001; low: OR 15.68; 95% CI 11.67-21.06; P < 0.001 vs high; type B = middle: OR 3.48; 95% CI 2.19-5.53; P < 0.001; low: OR 7.79; 95% CI 4.65-13.06; P < 0.001 vs high]. Various sensitivity analyses showed consistent results. High achievement rates of QIs were significantly associated with reduced in-hospital mortality. Evaluating each hospital's management using QIs would help to equalize treatment quality and demonstrate the evidence-to-practice gaps in real-world treatments for AAD.

In this study, a multimodality probe that simultaneously measures electroencephalograms, cerebral hemodynamics, and brain surface temperature was developed. This probe has six channels, and each channel has a platinum electrode for cortical electroencephalogram measurements, light emitting diodes, and photodiodes for hemodynamic measurements using near-infrared spectroscopy (NIRS), and a thermistor for measuring the cerebral surface temperature (BrT). A probe with a width of 8.0 mm and maximum total thickness of 0.7 mm was fabricated using flexible printed circuit board technology for chronic intracranial placement. Brain activity using the prototype probe at the resected site was measured and its function performance was evaluated. Characteristic epileptogenic abnormal electroencephalograms accompanied by polarity reversal between channels occurred at 16 min and 38 s. It was concluded that the brain cells consumed oxygen during the occurrence of abnormal electroencephalograms. At this time, no noticeable change in HbT values could be confirmed.

Guideline 大量出血症例に対する血液製剤の適正な使用のガイドライン宮田 茂樹 1) 板倉 敦夫 2) 上田 裕一 3) 碓氷 章彦 4) 大北 裕 5) 大西 佳彦 6) 香取 信之 7) 久志本成樹 8) 佐々木啓明 9) 志水 秀行 10) 西村 邦宏 11) 西脇 公俊 12) 松下 正 13) 小川 覚 14) 紀野 修一 15) 久保 隆彦 16) 齋藤 伸行 17) 田中 裕史 18) 田村 高廣 19) 中井 陸運 11) 藤井 聡 20)