11. Diversity is Strength: Creating a Safer Environment at Juntendo University Hospital / 医学教育

Juntendo University Hospital (1051 beds) set up a working group focusing on SOGI (sexual orientation and gender identity) in May 2021. To date, more than 300 staff members play a rale as ally members in rarious hospital departments to promote a safer environment for patients of all SOGI. This initiative has been spreading to the medical school and other parts of the university to ensure a safer space for everyone. Providing hospital staff opportunities to meet with LGBTQs people in person at a SOGI seminar seems to bring a transformative impact on the participants.　Understanding a patient's background is imperative to provide better care for any patient. This article illustrates how we facilitate the process of enabling hospital staff to support patients with various SOGI.

Effect of Sildenafil on Pulmonary Hypertension after a Case of Residual Shunt of Ventricular Septal Defect / 日本心臓血管外科学会雑誌

A 60-year-old man, who underwent repair of ventricular septal defect (VSD) 40 years previously, presented with dyspnea on effort and leg edema. Further examination showed residual VSD, mitral and tricuspid valve insufficiency, atrial flutter and pulmonary hypertension. We performed repair of the residual VSD, mitral valve replacement, tricuspid valve annuloplasty, and the Maze procedure. After surgery, systolic pulmonary arterial pressure decreased from 70 to 39 mmHg. On the 4th postoperative day, his hemodynamic state was stable and he weaned from ventilator. He showed hypoxia with sticky excretions, and reintubation was done 10 h after extubation. After intubation, pulmonary hypertension continued, nitroglycerine administration was not effective but inhaleted nitric oxide (NO) improved pulmonary hypertension. On the 15th postoperative day, sildenafil administration from nasogastric tube was started the day before extubation. On postoperative echocardiogram on the 35th postoperative day, the systolic pulmonary arterial pressure was 30-40 mmHg and left ventricular function was severely impaired because of the paradoxical movement of the ventricular septum after repair VSD. Sildenafil was safely used for the patient with heart failure and secondary pulmonary hypertension associated with congenital heart disease.

Lower Mini-Sternotomy for Direct Coronary Artery Bypass on the Beating Heart / 日本心臓血管外科学会雑誌

Although left anterior descending coronary artery (LAD) grafting with a left internal thoracic artery (ITA) on a beating heart via a small left anterior thoracotomy (LAST) has become widely accepted, significant limitations exist due to the limited surgeon experience, smallness of exposure, thus making harvesting of the ITA, visualization of the surgical field and anastomosis quite difficult. Patients often have significant pain and wound complications postoperatively. A lower mini-sternotomy approach in 4 patients was performed from December 1998 through January 1999. Results: The length of mini-sternotomy incision is 7 to 14cm. These operations were accomplished without morbidity or mortality. No patients required intraoperative conversion to conventional bypass. Postoperative angiography showed patency of graft without stenosis of the anastomosis in all 4 patients. The patients did not complain of significant pain and their postoperative hospital stay was 5 to 11 days. The lower mini-sternotomy approach or“xyphoid” approach proposed by Benetti seems to be an excellent novel approach giving the freedom of extension of the incision if needed with satisfactory exposure for left ITA harvest and access to LAD as well as the distal RCA, and causes less postoperative incisional pain.

Coronary Artery Revascularization in Chronic Hemodialysis Patients / 日本心臓血管外科学会雑誌

We controlled the hemodilution and electrolyte levels during coronary artery revascularization in chronic hemodialysis patients by hemofiltration during the period of extracorporeal circulation. Subjects comprised 7 chronic hemodialysis patients (males, average age 53) undergoing coronary artery revascularization in our department from January 1988 to December 1989. All patients had been undergoing hemodialysis for chronic renal failure and in one patient, after admission, continuous ambulatory peritoneal dialysis (CAPD) was additionally performed. During surgery, the dialyzer was equipped with an extracorporeal circulation circuit and the electrolyte level and hemodilution were adjusted using transfusion (1, 270±372ml). A large infusion volume (12, 657± 3, 966ml) was maintained and removal of water was carried out by ultrafiltration. After surgery, all patients underwent hemodialysis twice or more by the 3rd day of recovery. Concentrations of electrolytes were maintained at appropriate levels throughout the day of surgery except for one case of postoperative hypokalemia, but no marked changes in hemodynamics were observed during and after surgery. Hemofiltration during extracorporeal circulation is safe and useful in coronary surgery because it is simpler and requires less time than hemodialysis.