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The Robot-assisted Cardiac Surgery Council (RACSC) was established in 2015, and consists of the members of three closely related surgical societies and associations. The RACSC conducts the review and approval of applicant surgeons and institutions. A registry system has also been established through the Japan Cardiovascular Surgery Database-National Clinical Database( JCVSD-NCD). For the last five years, including the time when robotic mitral valve surgery was first approved as a procedure covered by the Japanese social insurance system in 2018, a total of 1,161 patients were enrolled in the JCVSDNCD, with an increase of nearly 500 cases per year. These cases underwent operations in 25 approved hospitals. The mean patient age was 59±13 years( range:20-90 years), and the male to female patient ratio was 1.8 male dominant. The most common procedure was mitral valve reconstruction, and 79% of all patients underwent annuloplasty. The mean operative time was 238±100 min, the mean cardiopulmonary bypass (CPB) time was 158±69 min, and the mean aortic cross-clamp (AXC) time was 102±49 min. When these results were compared with those of the Cleveland Clinic, which treated more than 1,000 cases as an initial institutional experience, both CPB and AXC times were nearly the same. It is believed that 200 cases are needed to stabilize the CPB and AXC time. Currently in Japan, only 3 or 4 out of the 25 approved hospitals have performed more than 200 cases over the past 5 years. The 30-day hospital mortality and redo operation rate for persisting mitral regurgitation was 0.3% and 0.6%, respectively, almost equivalent to that of the Cleveland Clinic. We believe that the 5-year result for robotic mitral surgery in Japan is acceptable. It is of note, however, that the length of hospital stay was 10.8±7.6 days, much longer than that of patients at the Cleveland Clinic( 5.2±2.8 days), and the homologous blood transfusion rate was 40.3%, twofold higher than that of the Cleveland Clinic( 20.5%). Therefore, the full benefits of less invasive robotic mitral repair surgery have not yet been achieved. Further improvements in results are both essential and anticipated.

Chronic kidney disease(CKD) is an important risk factor of open heart surgery. In addition, worsening of kidney function after the surgery leads to poor prognosis long-term. It is therefore crucial to protect the kidney function by intensive perioperative management in open heart surgery. In the patients having stage 3-4 CKD, mean arterial pressure needs to be higher than 70 mmHg and cardiac index needs to be greater than 2.4 intraoperatively and postoperatively. Continuous right heart monitoring by Swan-Ganz catheter is useful for this purpose. In the patients having stage 5 CKD, systemic complications need to be thoroughly evaluated preoperatively. Hemodialysis and serum potassium control during the extracorporeal circulation is important to minimize delay of postoperatively recovery. For coronary artery bypass grafting, off-pump approach would be a good option in stage 3-4 and stage 5 CKD patients.

The advent of transcatheter aortic valve implantation (TAVI) has been rapidly evolving the treatment of the severe aortic stenosis in patients with comorbidities that lead to being high-risk for conventional aortic valve replacement. The patient selection for TAVI is carefully made by a multidisciplinary heart team. An accurate preoperative assessment of the computed tomography angiography and transesophageal echocardiography are necessary for procedural success. In Japan, SAPIEN XT and CoreValve are available, and Lotus Valve is under clinical trial. So far, TAVI is an attractive treatment because the early outcome and the intermediate-term durability are favorable. An answer to a question of whether the indication for TAVI is able to expand to low- or intermediate- risk patients depends on the long-term durability.

Minimally invasive surgery is an attractive choice for patients undergoing major cardiac surgery. We review the history of minimally invasive valve surgery in this article. Due to many innovations in surgical tools, cardiopulmonary bypass systems, visualization systems, and robotic systems as well as surgical techniques, minimally invasive cardiac surgery has become standard care for valve lesion repair. In particular, aortic cross-clamp techniques and methods for cardioplegia using the Chitwood clamp and root cannula or endoballoon catheter in combination with femoro-femoral bypass systems have made such procedures safer and more practical. On the other hand, robotically assisted surgery has not become standard due to the cost and slow learning curve. However, along with the development of robotics, this less-invasive technique may provide another choice for patients in the near future.

Minimally invasive surgery is an attractive choice for patients undergoing major cardiac procedures. This paper focuses on minimally invasive mitral valve repair and robotic surgery using the da Vinci Surgical System. Minimally invasive mitral valve repair is usually performed through a right minithoracotomy with direct vision. The techniques used in this procedure are similar to those in open surgery. The outcome of minimally invasive mitral valve repair is also equivalent to that of open surgery, with high levels of patient satisfaction. On the other hand, minimally invasive cardiac surgery using the da Vinci Surgical System has not been approved in Japan except for internal mammary artery harvesting. A Japanese clinical trial of da Vinci surgery for mitral valve repair and atrial septal defect closure has been completed and approval is awaited. Although da Vinci surgery is technically demanding, this less-invasive technique may provide another choice for patients in the near future.

In the field of cardiovascular surgery, cardiac computed tomography (CT) has served an important role in association with the improvement of the spatial and temporal resolution. Because CT angiography (CTA) provides more available information than plain CT, CTA has been increasingly used to access the coronary arteries and graft patency after coronary artery bypass grafting (CABG). Recently, minimally invasive cardiac surgeries, including CABG with left mini-thoracotomy and mitral valve surgery with right mini-thoracotomy, are revived, which requires preoperative CTA to make a strategy of incision placement on the basis of anatomical relationship between the target structure of the heart and the thorax. In Japan, transcatheter aortic valve implantation (TAVI) was approved in the late 2013, and is expected to be widely performed in the future. CTA is extremely useful for TAVI patients to determine the choice of the valve size and the surgical approach. CT provides many other valuable findings to us, but if we cannot fully leverage it in the daily cardiovascular surgery, its value is decreased. We have to acquire enough skill to maximize the performance of CT in the practical clinical setting.

Objective: Recently, some technical improvements in aortic arch repair have brought better outcomes. In this article, we reviewed our surgical results of open arch repair using selective cerebral perfusion(SCP)., Methods: Between 2001 and 2012, a total of 813 patients (median age of 70 years) underwent total arch replacement with SCP. We preferably use the right axillary artery cannulation for SCP and stepwise technique for distal anastomosis. The temperature at hypothermic circulatory arrest was moder ate in 46%, and deep in 54%.Of them, 22% had emergency surgery., Results: Early mortality was 5.2% in all. The incidences of permanent( PND) and temporary neurological deficits were 3.4% and 7.3%. No spinal cord injury occurred, even with moderate hypothermia. The cumulative survival rates were 78.4% and 49.9% at 5 and 10 years, respectively. The freedom from arch reoperation was 98.0% and 96.2% at 5 and 10 years, respectively., Conclusions: Open total arch replacement using selective cerebral perfusion with some technical improvement provides favorable outcome, even in long-term period.

Valve surgery in patients with prior coronary artery bypass grafting (CABG) is challenging procedure. If the patent graft was injured during resternotomy or dissection of the graft, operative mortality and morbidity was significantly increased. To avoid the injury, left internal mammary artery( LIMA)should be passed through under the left lung and right internal mammary artery (RIMA) should be avoided if valve surgery is anticipated in the future. We invented "internal mammary artery (IMA)-non-touch procedure" which included systemic hyperkalemia and mild hypothermia during cardiopulmonary bypass without touching IMA. With this technique, cardiac arrest can be achieved without myocardial injury avoiding IMA injury. Available transcatheter aortic valve replacement (TAVR) is awaited in Japan. Patent graft is no longer a risk for TAVR, although long term results have not been obtained. Therefore, once TAVR becomes available, TAVR can be the standard therapy for aortic valve replacement( AVR) in patients with prior CABG.

Since the organ transplantation law was passed, we performed 50 heart transplantation at National Cerebral and Cardiovascular Center. Of those, 2 patients have been doing well over 13 years and 10 years survival rate was 93.4%.During those years, we performed 139 applications of left ventricular assist systems( LVAS). Initially, extracorporeal LVASs had been used. Now, 2 implantable LVAS were approved by medical insurance as bridge to transplant in 2011. Now, our 1st option as bridge to transplantation(BTT) is implantable LVAS.

As of September 30, 2011, a total of 113 patients with end-stage heart failure had undergone heart transplantation in Japan, and the early and late (10-year) survival rates appeared better than those reported by the registry of the International Society of Heart and Lung Transplantation. Among the risk factors negatively affecting survival, utilization of both left ventricular assist devices (LVADs) and marginal donor hearts were higher among Japanese patients, and among the factors favoring survival, younger adult recipients and fewer cases of ischemic cardiomyopathy were noted in Japanese patients. Although only a few patients have reached a survival period longer than 10 years, none has required retransplantation or died due to cardiac allograft vasculopathy (CAV). CAV may develop later in Japanese heart transplant patients than in those with mixed ethnic transplants. In addition, the survival rate with newer LVADs has improved dramatically recently, and therefore selection criteria for the use of an LVAD or heart transplantation require further investigation depending upon the characteristics of candidates with profound heart failure.

Objectives: Ischemic cardiomyopathy (ICM) associated with advanced ventricular remodeling remains a surgical challenge. The purpose of this study was to evaluate long-term clinical and echocardiographic results following surgical ventricular reconstruction (SVR)., Methods: From 1999 to 2009, 34 consecutive ICM patients with ejection fraction less than 35% underwent SVR. Cardiac catheterization was examined before and after surgery. Clinical follow-up and serial echocardiographic examinations were performed at baseline, 1 month, and annually thereafter., Results: Hospital mortality was 6% (n = 2) and the overall survival rate after 5 years was 70%. Angiogram findings revealed a reduction of left ventricular end-systolic volume index (112 +/- 47 ml/m2 vs. 62 +/- 28 ml/m2, p < 0.05) and improved left ventricular ejection fraction at 1 month after SVR. Serial echocardiogram findings demonstrated that significant reduction of left ventricular dimension was maintained along with well-controlled mitral regurgitation until 3 years after SVR., Conclusion: In ICM patients, SVR restored left ventricular geometry and functions. Long-term followup with optimized medical treatment is necessary after SVR.

Among cardiac arrhythmias, surgical treatment for atrial fibrillation (AF) has developed the most in recent years. Instead of the cut-and-saw method in the Cox-Maze procedure, which had been the gold standard for AF surgery, surgical ablation systems using various energy source and devices have been utilized to facilitate rapid, safe creation of lines of conduction block under direct view. The challenge of establishing a minimally invasive off-pump surgical ablation procedure via the thracoscopic approach continues.

There are advantages to using aortic homografts as aortic valve replacements (AVR), particularly in patients with complex infective endocarditis. To determine the importance of a domestic homograft valve bank, our 23 surgical cases of homograft-AVR were reviewed. Since 2000, the Tissue Bank of the National Cardiovascular Center has supplied 23 aortic homograft valves for the treatment of complex aortic valve endocarditis. Fourteen of 23 patients had prosthetic valve endocarditis and 20 patients had an aortic annular abscess. The early mortality rate was 17% (4 patients), in all of whom prosthetic valve replacement had been performed previously. No recurrent endocarditis and no recurrent aortic regurgitation were noted at medium-term follow-up. An aortic homograft valve is the conduit of choice in cases of infective endocarditis and the importance of a domestic homograft valve bank should be recognized.

The number of coronary artery bypass grafting (CABG) has reached more than 21,000 cases per year in Japan, and the operative mortality has decreased less than 1% including emergent operation. There are 2 trends in CABG. One is the revival and wide spread of off-pump CABG (OPCAB). The other is multiple arterial coronary revascularization. In 2004 and 2005, 60% of all CABG procedures in Japan were performed without cardiopulmonary bypass. For competition with percutaneous coronary intervention with drug eluting stents and better long-term outcomes, CABG with only arterial grafts was carried out in 52% of total cases and 66% of OPCAB cases. OPCAB with multiple arterial grafts has been becoming the standard CABG in Japan. We reviewed OPCAB and arterial CABG including new technology.

The number of coronary artery bypass grafting (CABG) procedures has reached more than 20,000 per year in Japan, and the operative mortality rate has decreased to less than 1.5% including emergent surgery. The mortality and morbidity rates of CABG are still high in patients with risk factors such as cerebrovascular disease, chronic renal failure on hemodialysis, atheromatous and calcified ascending aorta, and older age when cardiopulmonary bypass is used. Minimally invasive direct coronary bypass on a beating heart through a small left lateral anterior thoracotomy, in which the left internal thoracic artery (LITA) is used to revascularize the left anterior descending artery, was introduced for high-risk patients with single-vessel disease in the mid-1990s, although is not widely performed at present. Since the late 1990s off-pump coronary artery bypass grafting (OPCAB) has been widely performed as a treatment for multivessel disease through a median sternotomy with the evolution of stabilizers and apical suction devices, refined anesthetic management, and sophisticated surgical techniques. In 2004, 60% of all CABG procedures in Japan were performed without cardiopulmonary bypass. Due to competition from percutaneous coronary intervention with drug-eluting stents and better long-term outcomes, CABG with arterial grafts alone was carried out in 52% of total cases and in 66% of OPCAB cases. OPCAB is becoming the standard CABG in Japan.

After a new medical expense system "DPC (Diagnosis Procedure Combination)" had been introduced in 2003, the change in the medical treatment fee was evaluated according to each cardiovascular surgical field. Application of the DPC is limited to hospitalization fee in the general ward by a fixed daily amount The former payment system remains for operation, anesthesia, and some invasive examinations such as cardiac catheterization, therefore, the influence of the DPC introduction on cardiovascular surgery was minimum. A lot of problems are still left, however, for the classification of diagnosis, especially in a congenital heart disease, and the fee setting of intensive care. It is required also to reconsider serious cases, advanced complications and methods of life support. In the field of cardiovacular surgery, the treatment is so risky and so expensive, that more detailed analysis should be necessary by establishment of data base system.