|Makoto Hibino＊1)||Junya Sugiura1)||Yasuhiko Terai1)|
|Akio Koyama1)||Shun Watanabe1)||Hideto Shimpo2)|
|Tetsuya Kitagawa3)||Hitoshi Yokoyama4)||Yuichi Ueda5)|
（The Japanese Society for Cardiovascular Surgery Under-Forty1), Senior Adviser2), and Chair3), U-40 Management Committee, The Japanese Society for Cardiovascular Surgery, Tokyo, Japan, Executive Director4), and President5), The Japanese Society for Cardiovascular Surgery, Tokyo, Japan）
Objectives:Many reports have investigated the work environment of physicians and reported the association between work environment, burnout, and the quality of medical care. We aimed to determine the key to improving the work environment by analyzing the results of a Japanese survey for young cardiovascular surgeons. Methods:A survey on work environment was performed among the young members of The Japanese Society for Cardiovascular Surgery（●40 years of age）to measure their job satisfaction for 9 items:operation, perioperative work, number of hours working or sleeping, board affairs（application or renewal of board certification), motivation, salary, days off, quality of life, and mental status. Univariate and multivariate analyses using 16 factors for the work environment（age, number of years in practice, gender, subspecialty, board certification in surgery, board certification in cardiovascular surgery, primary practice hospital, workdays and nights on duty in a primary practice setting, workdays and nights on duty outside primary practice, total annual income, overtime work hours, overtime entitlement, gap in overtime work and entitlement, and presence of an intensive care unit［ICU］managed by ICU physicians）were performed to identify the risk factors for dissatisfaction. Results:The survey was completed by 327 of 1,304（25.1% response rate）young members of the Japanese Society for Cardiovascular Surgery. The respondents had an average of 8.5±3.5 years in practice, and 292（89.3%）respondents were male. Only 14.2% of the responding young surgeons reported no dissatisfaction in any items. In all items, the young surgeons were most satisfied with operation（34.6% of all responders). Age, years in practice, female gender, board certification in surgery, working at a university hospital, workdays in a primary practice setting, and workdays outside a primary practice setting were identified as significant factors for dissatisfaction, while a subspecialty in vascular surgery, total annual income, board certification in cardiovascular surgery, and the presence of an ICU managed by ICU physicians were identified as significant factors against dissatisfaction in the work environment. Conclusions:Our analyses of the survey results identified a number of risk factors for dissatisfaction in the work environment among young cardiovascular surgeons. Regarding the quality of medical care, respondents hoped for a reduced burden on surgeons and the establishment of a work-shift system in the cardiovascular department and an interdisciplinary team including an ICU physician. Multidimensional analyses including job satisfaction, rewards as training, and a quantitative evaluation of the quality of medical care will be necessary to clarify the corresponding relationship between consumers and providers of cardiovascular surgery in the work environment.
Jpn. J. Cardiovasc. Surg. 46:149-156（2017）
Keywords：training environment;work environment;team medical care;job satisfaction;burnout
|Jun Hayashi＊||Seigo Gomi＊||Tetsuro Uchida＊|
|Azumi Hamasaki＊||Yoshinori Kuroda＊||Atsushi Yamashita＊|
|Ken Nakamura＊||Daisuke Watanabe＊||Shingo Nakai＊|
|Akihiro Kobayashi＊||Mitsuaki Sadahiro＊|
（Second Department of Surgery, Yamagata University Faculty of Medicine＊, Yamagata, Japan）
A 14-year-old women who had a history of aortic root replacement at 7 years old admitted our hospital due to dilatation of aortic arch aneurysm. Loeys-Dietz syndrome was diagnosed when she was 10 years old. Computed tomography showed 70 mm proximal arch aneurysm. Operative findings revealed brachiocephalic artery and left common carotid artery branched from aneurysm. Partial arch replacement was performed and distal anastomosis was made between left common carotid artery and left subclavian artery. Close observation by CT regularly is necessary and undergo aortic repair not to miss the timing of surgery.
Jpn. J. Cardiovasc. Surg. 46:157-160（2017）
Keywords：Loeys-Dietz syndrome;Marfan syndrome;aortic aneurysm;reoperation
|Naoki Asano＊||Kazunori Ota＊||Kazuho Niimi＊|
|Koyu Tanaka＊||Masahito Saito＊||Shigeyoshi Gon＊|
|Hirotsugu Fukuda＊＊||Hiroshi Takano＊|
（Thoracic and Cardiovascular Surgery, Dokkyo Medical University Koshigaya Hospital＊, Koshigaya, Japan, and Cardiac and Vascular Surgery, Dokkyo Medical University Hospital＊＊, Shimotsuga-gun, Tochigi, Japan）
A 46-year-old man who developed fever and general fatigue was referred to our hospital with suspicion of infective endocarditis. A ventricular septal defect had been previously diagnosed. Transthoracic echocardiography revealed vegetation on the aortic, mitral, and pulmonary valves, and each valve had significant regurgitation. An emergency operation was performed because of congestive heart failure. The aortic and mitral valves were replaced with mechanical valves. The pulmonary valve was repaired;the anterior leaflet was resected and replaced by glutaraldehyde-treated autologous pericardium. The patient’s postoperative course was uneventful. Recurrence of infection was not observed for 3 years after the operation. Triple-valve endocarditis, especially that involving a combination of the aortic, mitral, and pulmonary valves, is rare. Involvement of multiple valves on both sides of the heart may be attributed to a congenital intracardiac shunt. Early surgical intervention may be useful to control infection and heart failure, as in the present case.
Jpn. J. Cardiovasc. Surg. 46:161-164（2017）
Keywords：infective endocarditis;congenital intracardiac shunt;pulmonary valve repair;triple valve;autologous pericardium
|Tatsuhito Ogawa＊||Hisao Suda＊||Yosuke Nakai＊|
（Department of Cardiovascular Surgery, Nagoya City East Medical Center＊, Nagoya, Japan, and Department of Cardiovascular Surgery, Nagoya City University Graduate School of Medicine＊＊, Nagoya, Japan）
A 58 year-old man was referred to our hospital with a fever after dental treatment. He had undergone an operation for aortic root replacement 9 months earlier. Streptococcus species were cultured with venous blood culture. An echocardiogram revealed vegetation attached to the prosthetic valve. The prosthetic valve function was good and he did not suffer from heart failure, therefore he was treated with antibiotics. Five days after starting antibiotics, we observed embolization of the brain and the kidney as well as an elevation of his inflammatory reaction. Accordingly, we performed emergency surgery. There was no paravalvular abscess or valve dysfunction, so we simply resected the vegetation and debrided the surrounding tissue. Post-surgical antibiotic therapy was continued for 5 weeks and then he was switched to oral medication. Three years after surgery, he is free from any PVE recurrence.
Jpn. J. Cardiovasc. Surg. 46:165-168（2017）
Keywords：prosthetic valve endocarditis;reoperation;vegetation resection
|Hiroki Ikeuchi＊||Kenji Mogi＊||Manabu Sakurai＊|
（Division of Cardiovascular Surgery, Institution of Cardiovascular Center, Funabashi Municipal Medical Center, Funabashi, Japan）
A 75-year-old man, who had undergone aortic valve and ascending aorta replacement at the age of 73 years, was admitted to our hospital with one week of fever. Blood culture showed growth of Streptococcus bovis and echocardiography showed vegetation on the prosthetic valve. Although antibiotic treatment was commenced, he complained of abdominal pain, and computed tomography showed a superior mesenteric artery embolism. The abdominal pain improved with fasting, but echocardiography showed another vegetation, and re-aortic valve replacement was performed to prevent embolism recurrence. When he resumed eating postoperatively, he again complained of abdominal pain and computed tomography showed mesenteric ischemia. The necrotic intestine was extensively resected and he recovered successfully. A superior mesenteric artery should be revascularized to 2/11 prevent perioperative mesenteric ischemia when cardiac surgery complicated by acute superior mesenteric artery embolism is performed.
Jpn. J. Cardiovasc. Surg. 46:169-172（2017）
Keywords：infective endocarditis;prosthetic valve infection;superior mesenteric artery embolism
|Hideaki Kanda＊||Yukinori Moriyama＊||Yutaka Imoto＊＊|
|Yoshihiro Fukumoto＊||Takayuki Ueno＊||Kazuya Terazono＊|
（Department of Cardiovascular Surgery, Kagoshima Medical Center＊, Kagoshima, Japan, and Cardiovascular and Gastrointestinal Surgery, Kagoshima University Graduate School of Medical and Dental Sciences＊＊, Kagoshima, Japan）
We report 4 cases of aortic graft replacement for Kommerell diverticulum（KD）and the aberrant subclavian artery（ASA). In two patients who had a right-sided aortic arch, KD and the left ASA, we performed descending aorta replacement and in-situ reconstruction of the left ASA via a right lateral thoracotomy. Third patient had a left-sided aortic arch, KD and the right ASA, in whom we performed descending aorta graft replacement via a left lateral thoracotomy with ostial closure of the right ASA. Fourth patient had a left-sided aortic arch, KD and the right ASA, and complicated by acute type A aortic dissection. We performed a total arch repair with frozen elephant trunk procedure via a median sternotomy. All 4 patients survived operations and discharged from the hospital with symptom relief. The choice of approach, a thoracotomy or a median sternotomy, should be based on patient-specific anatomy and extent of graft replacement.
Jpn. J. Cardiovasc. Surg. 46:173-176（2017）
Keywords：aberrant subclavian artery;thoracic aneurysm;Kommerell diverticulum
|Koji Kawago＊||Takehito Mishima＊||Takashi Wakabayashi＊|
|Yuko Tosaka＊||Satoshi Nakazawa＊||Hiroshi Kanazawa＊|
（Department of Cardiovascular Surgery, Niigata City General Hospital＊, Niigata, Japan）
We report a case of reoperation for proximal and distal pseudoaneurysmal formations of the ascending aorta with aortic regurgitation（AR）after an ascending aorta replacement for acute type A aortic dissection. The patient was a 69-year-old woman who had undergone ascending aorta replacement for acute type A aortic dissection six years previously. Subsequent development of pseudoaneurysms of the ascending aorta and aortic regurgitation were revealed by computed tomography and echocardiography respectively. We chose debranch Thoracic Endovascular Aortic Repair（TEVAR）with a staged approach. First, aortic valve replacement, patch closure of proximal pseudoaneurysmal formation, coronary artery bypass, and ascending aorta-axillary artery bypass were performed. Two weeks later, debranching and TEVAR were performed. Cardiac reoperation for proximal and distal pseudoaneurysmal formations of the ascending aorta with aortic regurgitation after an ascending aorta replacement is known to be high risk. Nevertheless we performed the operation safely in two-stage surgery.
Jpn. J. Cardiovasc. Surg. 46:177-181（2017）
Keywords：pseudoaneurysmal formations;aortic regurgitation;acute aortic dissection;postoperative complication;debranch TEVAR
|Shohei Yoshida＊||Shinichi Hiromatsu＊||Kentaro Sawada＊＊|
|Takahiro Shojima＊||Ryo Kanamoto＊||Shinichi Imai＊|
|Hiroyuki Otsuka＊||Hiroyuki Tanaka＊|
（Department of Surgery, Kurume University School of Medicine＊, Kurume, Japan, and Fukuokaken Saiseikai Futsukaichi Hospital＊＊, Fukuoka, Japan）
A 60 year old man presented with a history of right leg claudication which occurred after walking a distance of 200m. He had no history of cardiovascular risk factors or trauma in the lower extremities. Palpation disclosed no right popliteal or pedal pulse. Ankle-brachial pressure index（ABI）was 0.60 on the affected side. Computed tomography（CT）demonstrated the presence of a highly stenotic lesion in the right popliteal artery due to compression from periarterial polycystic masses. Magnetic resonance imaging（MRI）revealed no communication to the knee joint bursa. Further, angiography showed a beak-like severe stenosis on the knee of the right popliteal artery. Based on the results of these three imaging techniques we confirmed the diagnosis of cystic adventitial disease（CAD). The patient underwent a surgical exploration of his popliteal artery through a posterior approach. Evacuation of all cysts by longitudinal incision of his adventitia yielded yellow mucoid gelatinous material. The popliteal artery was replaced using the great saphenous vein because the previous imaging showed thrombus formation at the cyst site. He had an uneventful postoperative recovery with ABI of 1.10.
Jpn. J. Cardiovasc. Surg. 46:182-185（2017）
Keywords：cystic adventitial disease;claudication