Objective: The utility of a multi-disciplinary work sheet for the Nichidai acute heart failure (AHF) program was investigated in the AHF hospitalized patients. Methods and Results: The subjects were 45 patients with clinical diagnoses of AHF, who were admitted to Nihon University Itabashi Hospital from February 2011 to October 2011. Standard rehabilitation was performed in 25 patients (control group) and the remaining 20 (work sheet group) underwent rehabilitation according to the Nichidai AHF program multi-disciplinary work sheet. There were no differences in the baseline characteristics between the two groups. The start of each rehabilitation phase was significantly earlier (5.3±2.0 days vs 15.7±2.3 days for 50 m, 6.2±1.7 days vs 16.8±1.6 days for 100 m, and 8.0±1.8 days vs 24.2±1.8 days for 200 m walk training, P<0.05 for each), and hospital stay shorter for the rehabilitation in the work sheet group than the control group (20.6±2.2 days vs 32.0±3.6 days, P<0.05). Although no adverse events were observed in either group, the 6-min walk distance slightly improved in the work sheet group. Conclusions: The multi-disciplinary work sheet helped share patient information, and shortened the hospitalization. Sharing patient information and a multi-disciplinary comprehensive management program are important for safely accomplishing early ambulation for the patients. Our data will drive the efforts to perform further studies on the impact of early cardiac rehabilitation for AHF patients.

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Objective: The purpose of this study was to assess the clinical results of coronary artery bypass grafting (CABG) in patients with carotid artery disease and the utility of quantitative mapping of regional cerebral blood flow using single photon emission computed tomography (SPECT). Methods: Between April 1993 and December 2012, 1407 patients underwent CABG at our institution. Of these, 97 patients (age, 69.7 years; 81.4% male) had cervical carotid occlusive disease. Cerebral hemodynamics was examined in these patients using SPECT, and the treatment course was decided accordingly, through strategic discussion with brain surgeons. Results: Off-pump coronary artery bypass was performed only in 35 patients (36.1%) to avoid potential sudden hemodynamic derangement. Prophylactic cerebrovascular reconstructive surgery with concomitant carotid endarterectomy was performed in 19 patients (20.0%) with severely reduced cerebral perfusion reserve. Four patients (4.1%) experienced perioperative stroke, attributable to cardioembolic infarction due to postoperative atrial fibrillation (2 patients) and atherothrombotic infarction (artery-to-artery embolus) (2 patients); none of the patients experienced stroke due to hemodynamic infarction. Conclusion: To prevent perioperative hemodynamic infarction in patients with carotid occlusive disease undergoing CABG, it is important to localize Stage II disease using brain SPECT and to determine the ideal surgical strategy for stabilizing intraoperative hemodynamic status.

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We investigated the usefulness of PH-ECG (pre-hospital 12-leads electrocardiogram) performed by paramedics during emergency ambulance transportation to the reperfusion therapy of acute myocardial infarction. Subjects: 882 catheterization patients of acute myocardial infarction admitted by Yokohama Cardiovascular Workshop Emergency Medical System from 2010 through 2012. Methods: Retrospect study on time from door-to-cardiac catheter laboratory time (D2CCL), door-to-balloon time (D2B), and door-to-reperfusion time (D2R) comparing with type and part of the infarction and having PH-ECG or not. Results: In both the group with all cases and the group with ST-elevation myocardial infarction (STEMI), significant reductions of the D2CCL and D2R were observed in the patients who underwent PH-ECG as compared to the patients who did not undergo PH-ECG. In non-ST elevation myocardial infarction (NSTEMI) group, significant was reductions of the D2R. In the comparison depending on the location of the infarction (anterior wall, inferior wall, posterior/lateral wall), significant reductions of the D2CCL and D2R were observed with implementation of PH-ECG. Conclusion: Our findings suggested that implementation of PH-ECG of AMI patients may reduce the time to reperfusion not only STEMI group but also NSTEMI group. PH-ECG is expected shortening to reperfusion time regardless of an infarction site.

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Objective: Although the introduction of the infarct exclusion technique has improved outcomes for post infarction ventricular septal perforation (VSP), a residual shunt is still problematic. We describe a new technique for repairing the VSP using a double patch repair with infarction exclusion method. Patients and Methods: Between October 2010 and October 2012, 4 patients underwent VSP closure with new technique (male 2, female 2). Three patients had anterior infarction and 1 patient had posteroinferior infarction. Double patch suture for VSP was performed through single ventricle approach and infarct exclusion was added. Results: Double patch repair with infarct exclusion through left ventricle was achieved in three patients. Double patch repair or double patch repair with infarct exclusion through right ventricle was achieved in 1 patient. All patients discharged without any complications and preserved normal shaped ventricular septum and left ventricular function. Conclusion: This new technique can support various size and lesion VSP without residual and may improve outcomes of VSP.

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In Off-pump CABG, internal thoracic artery is becoming main bypass graft. In most facilities, we need to clamp and hold the graft for anastomosis. However, graft can be damaged by clamping or holding. Therefore, gentle graft handling is very important. We introduced the new graft holder for sequential anastomosis. Gentle Balloon Stopper^® (GBS) is compact and has easy handling. We have not experienced any traumatic graft injury. GBS is safe and useful for sequential anastomosis in OPCAB.

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A 64-year-old male was admitted to our hospital in the state of a cardiogenic shock with dyspnea. Electrocardiography and trans-thoracic echocardiogram showed an inferior myocardial infarction and coronary angiography revealed a total occlusion in segment 1 of right coronary artery. Percutaneous coronary intervention with bare-metal stents was performed under intra-aortic balloon pumping support, but acute mitral regurgitation was occurred during the procedure. Emergency mitral valve replacement and also optimal medical therapy (inotropic agent, diuretics, Carperitide, etc.) was performed immediately, but congestive heart failure was uncontrolled after operation. Tolvaptan was administered through the gastric tube at 3 days after operation, and the increase of urine volume was accepted without worsening a hemodynamics and a renal function, and congestion heart failure was improved gradually and could wean from the respirator in the 8 days after operation. Tolvaptan was administered for 5 days, the patient showed no worsening of heart failure even after stopping the administration of tolvaptan, and the patient was discharged in the 33 days after operation. Administered of Tolvaptan for the prolonged heart failure after a cardiac surgery was safe and effective.

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High-flow nasal cannula system, which supplies a high flow of heated and humidified oxygen, may be an effective and safe respiratory therapy to a serious respiratory failure. Because the system on the market is very expensive, we tried to construct the system using in-hospital equipment together. Our original high-flow nasal cannula system was so easy to prepare and so good in clinical use.

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Coronary artery aneurysm (CAA) is defined as a localized coronary artery dilatation, which can be saccular or fusiform, and exceeds the diameter of the normal adjacent segments or the diameter of the patient’s largest coronary vessel by 1.5 times. CAA is an uncommon disease with an incidence of 0.3–4.9% in large angiographic series. CAA is observed most commonly in the right coronary artery, and least frequently in the left main coronary artery. It has been demonstrated that atherosclerosis is the main cause of CAA in adults, and Kawasaki disease in children and adolescents. The natural history and prognosis of CAA remain obscure, and management of the published recommendations are based on anecdotal experience. The most prevalent consequence of aneurysms in the coronary arteries is formation of a thrombus with distal embolization, vasospasm or vessel disruption at the site of wall injury. Therefore, therapeutic management in CAA involves both prevention of thromboembolic complications and percutaneous or surgical closure of the aneurysm entry. We report the cases of four patients who were treated surgically for CAA (non-Kawasaki disease) in our institute.

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