I can only entrust this surgery to you guys.
Somehow I want to keep that weaken heart until the myocardial sheet can be used.
Team dragon has brought a patient?
As expected, an excellent management consultant.
Making that patient as a gateway for team dragon to step into L&P.
It's best environment to show Asada-sensei's skill, isn't it?
Feel free to use anything that's usable.
HIT has been detected in the detailed examination result.
HIT: development of thrombocytopenia (a low platelet count), due to the administration of various forms of heparin, an anticoagulant.
We can't use heparin. If we can't use heparin,
The heart-lung machine won't be able to circulate. The operation can't be done...
With her condition right now, the operation can't be done.. I'm sorry...
If we stick to the myocardial sheet method,
The treatment can be done without giving a heparin.
But the approval of myocardial sheet hasn't been granted!
It's unfortunate, isn't it? No matter how great team dragon is...
The operation still be impossible, as the myocardial sheet can't be used,
But I guess they can't do anything, right?
A sudden mitral regurgitation has occurred.
Mitral valve regurgitation: happens when your heart's mitral valve doesn't close tightly, which allows blood to flow backward in your heart.
Mitral regurgitation? It's a ruptured chordae tendineae of the mitral valve.
Ruptured chordae tendineae can only be cure with surgery. However, the surgery is impossible.
What will you do, Asada? There will be cardiac arrest if it's continue being like this.
Bring the dopamine here. Ok.
Bring CV Catheter. Ok.
Kana.
This patient can't take either heparin or argatroban.
Argatroban: a direct thrombin inhibitor approved for the treatment of heparin-induced thrombocytopenia (HIT) type II.
Therefore the heart-lung machine won't be able to circulate.
Does the operation can be done without using heparin?
Without heparin, the heart-lung machine won't be able to circulate.
Then, can we do the operation without using the heart-lung machine?
Operating while the heart beats as it is?
No. This time is impossible. The tricuspid valve regurgitation has been increasing.
That means it's tricuspid valvuloplasty along with mitral valvuloplasty.
Valvuloplasty is the widening of a stenotic valve using a balloon catheter. Types include, Aortic and Mitral valvuloplasty (a minimally invasive therapeutic procedure to correct an uncomplicated mitral stenosis by dilating the valve using a balloon.)
Besides that, three overlapping operations are needed.
No matter how great Asada is, it's impossible to do those all these three without using the heart-lung machine.
Director, they said that mitral valve regurgitation has occurred to Fujiyoushi-sensei's patient earlier.
What?
What should we do?
Waiting, if it's possible. Waiting?
Waiting for the data that shows HIT antibody is removed from the body in several months.
Then we'll be able to use heparin when the HIT's antibody has gone?
Yes.
Therefore, can she endure it with internal medicine until then?
No. In this situation, the support from the Bud and PCPS of the heart-lung machine are needed.
Then even though we saved the heart temporarily,
The limbs and organs will be narcotized in the thrombus.
Saturation is decreasing.
I'll do an intubation. Ok.
Sensei.
By acknowledging the risk, we could only do the operation by using heparin.
What do you mean?
Saving life with a minimum operation in the shortest amount of time.
If we use heparin with patient's condition now,
It most likely will cause thromboembolism....
Thromboembolism: Formation in a blood vessel of a clot (thrombus) that breaks loose and is carried by the blood stream to plug another vessel.
If that happens, she can't be saved anymore.
No matter how great Asada is, I won't let him do such a nonsense.
Does it mean that there's no any other way?
There's a way!
Use hirudin!
Hirudin: an anticlotting agent that prevents blood clots from traveling through the bloodstream to clog up a vessel.
Hirudin?
It's a short-run!
Suck in mexiletine 50 mm. Ok.
What are they doing?! She won't wait any longer.
It's an anticoagulant which is secreted from the salivary gland of the leech.
Indeed it will be a replacement for heparin if it's hirudin.
Then, the heart-lung machine can be used.
The operation can be done.
But, we can't use hirudin. Huh? Why is that?
Hirudin has been used in the Western Countries, but it's an unauthorized medicine in Japan.
Unauthorized...
So, There's no hirudin in Japan in the first place.
Then, have it ordered from America... In that case, it won't make it !
Okay, thank you.
Hirudin will arrive after 10 minutes.
What? What do you mean? I've ordered it from the base.
Base? Do you mean U.S. military base?
Who exactly are you?
But hirudin is unauthorized in Japan right?
There's no other way.
An unauthorized medicine? This is bad.
Use the hirudin and do the operation !
I'll take the responsibility. But...
Being a doctor is the matter of giving your best for the patient.
If there's Hirudin, the patient will be saved. In that case, there's no reason to hesitate.
Ok.
Let's go. Patient is waiting.
Okamura-kun.
Translator: penk_88 | QC-typesetter: ryuulynn @IDWS
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The patient won't be saved if we don't do the operation immediately.
There's no other choice but to use Hirudin in the operation.
However, that is unauthorized...
Please use seventh operating room.
Huh? What?
The patient has been suffering from mitral valve regurgitation, right? We have to hurry.
But hirudin is...
This L&P Hospital has been approved for a medical special zone.
Medical special zone? Yes.
Hirudin is a medicine that has been used widely in Western Countries.
In here, any medicine has been specially allowed to use though it's unauthorized in Japan. As long as it has a worldwide standard.
Then... You can use hirudin.
Hurry go to the operating room!
Thank you.
Ah, You don't need to than since L&P and Sakurai Hospital are a partner.
It's an obvious thing. Yes.
Would you like to observe it together?
If it's them, it will be fine.
You know that I also have patients waiting for me...
But I was surprised Sakurai-sensei...
Never thought that you have a connection in the U.S Military...
Just have an old friend there...
With this, we can operate her... Yes.
However, the cardiac function is worsened. In this state, time for the heart-lung machine to circulate is limited to 60 minutes.
Three operations in 60 minutes?
If we take more than that, the hear-lung machine won't be able to pass through.
If so, the patient will be having a bedridden life.
But doing those three, tricuspid valvuloplasty, Mitral valvuloplasty and Overlapping in 60 minutes...
We don't have a choice but to do it in order to save the patient.
Ok. Let me be focus on the operation only.
Call Inohara-san.
It's unacceptable even for a second of loss in this operation.
Got it. I beg you, Asada.
Ok.
Yes, I understand. I'll go immediately.
There has been an emergency operation in L&P.
Please take care all patients here. Ok.
I understand.
Hurry.
Listen! Take a good look on what team dragon that I've brought up is like...
Seventh operating room. Hey, it's starting !
1, 2, 3.
Removing the stretcher..
Blood pressure has cut trough 50. Oxygen 100%.
Got it. Setting up the heart-lung machine.
Ok.
I'll be back soon.
Hirudin has arrived. It has come..
I'll go to do a hand-wash.
Let's circulate it with hirudin. Ok.
FFP. Also prepare the blood platelet!
FFP (Fresh Frozen Plasma): liquid portion of human blood that has been frozen and preserved after a blood donation and will be used for blood transfusion.
since the amount of blood loss might be larger than when we're using heparin. Ok.
It's seventh operating room.
Tomita Kana-chan's blood, please.
There's an additional order.
Please.
I'm Inohara from Sakurai General Hospital. Looking forward to work with you all.
Sorry I'm late.
Counting on you. Ok. Gauze.
It will be fine, okay...
It seems that hirudin have arrived safely too, doesn't it?
Yes. It means that next thing is to depend on their skills, right?
If it's them, they will be able to do it. They certainly will save the patient.
According to the ventricles, patient's heart is overextended,
Mitral valve and tricuspid valve, The conjugation of those two valves are imperfect,
causing a valve regurgitation.
Firstly, reefing the Tricuspid Annulus with Kay method, then implanting the artificial tendinous cord in the mitral valve, performing a valvuloplasty.
After that, stitching the fully extended left ventricle part according to overlapping method,
Reforming it to the proper size.
From this, we'll do tricuspid valvuloplasty and mitral valvuloplasty,
as well as left ventricular plasty according to overlapping method.
Ok.
We'll have the support from heart-lung machine ended in 60 minutes because of her cardiac hypo function.
Scalpel. Ok.
60 minutes? Based on patient's condition,
If we circulate the heart-lung machine longer than that, we won't be able to withdraw it.
Three operations in 60 minutes, is such a nonsense.
Yes. Besides, it's a plasty for mitral valve,
If they are prioritizing in time saving,
they should choose to do a artificial valve replacement surgery.
For ordinary surgeons, they would do it like that.
However, if you use an artificial valve for pediatric patients, it won't be able to support their growth.
Other than to do operations based on its level of difficulty,
Asada Ryuutarou is a man who would choose the best way for the patients. That's why I'm saying...
Ah? Huh?
Ijyuuin. He's still there!
4-0 prolin. Ok.
Tourniquet. Arase, do a bolus shot with hirudin pro-kilo 0.7.
9.8 ml hirudin has been inserted.
No different on vital.
Pump on. Pump on.
Out in a full flow.
Count start. Start counting.
The heart-lung machine has been circulated. from this, three operations in 60 minutes.
It's possible, if it's Asada. No, not just Asada.
The skills of all team dragon's members are extraordinary.
Looks like, those guys from Sakurai are doing an operation.
Really? Are they team dragon? Is she that girl?
Scalpel.
Tweezers. Ok.
The development of this operation field in front of you is an art.
The part that you want to operate are widen right in front of you immediately.
Second assistant is anticipating anytime, in order to make it easier for Asada-sensei to do the treatment.
It's a proof the he can do the same level operation as the surgeon.
And then, to make the surgeons be able to focus only to the operative fields,
Anesthetic control for a whole-body even for a small change without miss.
That nurse who's giving out the instruments also has an outstanding reflexes.
Restore the volume. Ok.
Scalpel. Coolie hook.
Pump sucker up. Sucking up.
This is team dragon.
I've never seen a beautiful operation like this before.
3-0 pledgets with dacron. Ok.
Scissors.
Leak test. Ok.
There's no regurgitation. Tricuspid valvuloplasty is done.
Tricuspid valvuloplasty is done already.
This might truly be finished in 60 minutes.
They have been advancing again. Next is mitral valvuloplasty.
Scalpel. Coolie hook.
I will prepare the artificial tendinous cord.
What's the matter, Asada?
What is it?
This is...
It's a vegetation. Huh?
Vegetation.
A lump of bacteria is attached on the valve leaflet.
In other words, it has been complicated by the infective endocarditis.
Infective endocarditis: an infection that can seriously damage heart valves and cause other serious complications if it is not treated quickly with antibiotics. Surgery is also often needed.
Infective endocarditis.
Nothing was reflected in the echocardiographic.
I guess it can't be detected..
Not just chordae reparation of the mitral valve,
but the valve reparation also required.
No other choice than a valve replacement.
No. I won't use an artificial valve for this patient.
I will do an angioplasty by compensating the self pericardium.
It won't be finished in 60 minutes, if we do that far.
Foamy sputum has come out. There's no way we can escape it.
If it's over than 60 minutes, she won't be able to be withdrawn from the heart-lung machine.
What will you do, Asada?
Ok. Ok. Haha...
Thank you very much. Ok.
Asada.
Yes.
What?
We'll make it be finished in time. There's no choice but to do it.
Ok. Got it.
Scissors. Ok.
The speed has increased even more.
But to have it be finished with just 40 minutes left is absolutely impossible.
No, If it's them, it can be done. If it's team dragon.
Do the glutaraldehyde treatment.
CV5. Ok.
Sucker up. Sucking up.
Ijyuuin, the size is 12x8. Ok.
5-0 prolin. Ok.
Leak test.
Mitral valvuloplasty is done.
How about the overlapping?
There's only 5 minutes left. Intracardiac reparation is perfectly done.
We should stop here. If we force to continue more than this,
The failure will also extend to the heart muscle that is still functioning.
Asada-sensei.
What's the matter, Asada? If you quit now, it will be hard to re-operate.
But continuing it is also too reckless.
It can be done if it's them!
I said it's impossible.
I will end the operation.
Things that we can do now is until here.
The overlapping... The operation...
is done.
Pump off.
Asada is lost.
Plasty of tricuspid valve and mitral valve are finished in a wonderful speed.
Moreover, doing a papilary muscle myectomy with an instant judgment in the situation where they have insufficient time as an addition.
To survive it alone, is a miracle.
It's not something like miracle to them.
She may be survived but her heart condition remains unchanged.
No. The minute when they took responsibilites on the operation,
Contraction of the residual myocardium has worsened.
To not be able to do the overlapping is not a mistake for Asada, it's a defeat.
Even if the operation ended just like this, The cardiomyopathy still remains as it is.
The heart failure will occur again soon.
Next, she won't be saved, as long as the transplantation hasn't been done.
Let's close the chest.
Ok.
The operation hasn't finished yet.
Fujiyoushi-sensei.
That is....
It's the myocardial sheet which is cultivated from patient's myoblast cells.
Myocardial sheet? Myocardial sheet is....
As expected from you, Asada. The amount of bleeding is only a few.
What do you mean? If the amount of bleeding is large,
The survival rate of the sheet will be bad.
In that case, we have to do this on another day.
However with this condition, we can do the treatment at the same time.
The burden to patient's body will also be minimized.
If we use myocardial sheet, it's similar with overlapping?
We can expect the greater effect from that.
But, is it really ok to use myocardial sheet?
Do it.
Tweezers. Spatula Ok.
After collecting the myocardial cells from patient's thigh,
Two pieces of the cultivated sheets with approximately four cm diameters and 0.2 mm thickness,
are stacked into one pair.
In order to strengthen the intensity, be sure to attach the sheet that has been carefully stacked so that the left ventricle is covered.
Attaching the myocardial sheet which are made from patient's own cells, to the part which heart function is weakening.
The heart-lung machine isn't needed. No risk of rejection too.
Furthermore, compare to the overlapping method, the recovery after the operation will be faster.
Amazing. It's certainly the most advanced method of treatment.
The world's first medical care is right in front of us. Huh? Where is it?
Isn't that only attaching with tweezers?
Changing the cells which are taken from the thighs to be the heart muscles, is certainly a revolution.
I'm witnessing the moment when the history is changed.
It looks like yuba, huh?
Yuba: Tofu skin.
The marriage between the highest level surgeons and the most advanced regenerative medicine.
With this, it's done.
Closing the chest.
The stages around the world
are looking forward to you all.
Kana?
The operation has safely succeeded. Thank you very much.
Re-operation won't be necessary anymore.
Sensei, thank you very much.
Thank you very much.
She did her best as well.
It's great that it will be in time for the school entrance ceremony.
But, why the myocardial sheet can be used?
I guess it's because the medical special zone. that hirudin also can be specially used here...
Hirudin and myocardial sheet are different...
Hirudin are being used in the Western Countries,
However, myocardial sheet treatment hasn't been done anywhere around the world yet.
I see.
Hurry. Excuse me.
It has started already.
Thank you for the hard works.
The operation is safely succeeded. In three months,
We can expect the recovery of the heart function with the effectiveness of the myocardial sheet.
I see. It's great. Yes.
However, the fact that having the U.S Military brought the hirudin here is...
What are you talking about?
Does Sakurai-sensei have a relation with the U.S Military?
Director? Uhm...
Excuse me.. In the TV now. Huh?
We've worked hard in order to extend Japan's most advanced medical care to the world.
Noguchi.
Medical internationalization Promotion Committee Chairman?
For example, the medical special zone.
In medical special zone, we are trying so that any treatments that has been approved overseas,
but hasn't been approved yet in Japan will be specifically permitted here.
Why does Noguchi? But,
That alone is not enough.
This badge...
Does he L&P's man too?
I want to dispatch the world's most advanced medical treatment from our country.
For that reason the Medical Internationalization Promotion Committee
has taken a new step.
It proceed the medical special zone one step further,
It's super medical special zone.
Super medical zone?
He thought about it, huh? Super medical special zone.
I'm also amazed by Noguchi-sensei's ability to take actions.
In super medical special zone,
any treatments that hasn't been done yet anywhere in the world,
will be done as a clinical trial which is specifically permitted.
And then today at 9.40 AM.
The first example of treatment in super medical zone at L&P hospital,
For patients with dilated cardiomyopathy,
The myocardial sheet Treatment was a great success.
We were able to use myocardial sheet because of Noguchi's power.
Why is such thing...?
Does it mean that this guy is drawing a picture in the back?
And also the patient of this operation
was a six years old girl.
If there's no myocardial sheet from this super medical special zone,
No matter how excellent the heart surgeon is,
this girl wouldn't be able to be saved, would she?
The government and fat pipe are in our hands it's because of Noguchi-sensei.
With this, team Dragon has made a large debt to Noguchi.
If there's myocardial sheet, the patient has be able to live with her own heart.
It's surely a treatment of dream.
Although it's Fujiyoushi-sensei's myocardial aheet...
Well then, let's introduce the leading person of the first Myocardial Sheet in the world.
L&P Medical Lab Researcher,
Fujiyoushi Keisuke-sensei.
Fujiyoushi Sensei?
Fujiyoushi Sensei in L&P?
Having the super medical special zone been approved
and pull in Fujiyoushi brilliantly as the exchange of myocardial sheet treatment there, right?
To prepare the suitable stage for the superstars to shine,
it's my job.
Myocardial sheet can be use? Yes.
Just now, this L&P Hospital,
has been certified as a super medical special zone, Fujiyoushi-sensei's myocardial sheet can be used.
Only in this L&P Hospital around the world,
you can save the patient by using Myocardial Sheet.
I will prepare it immediately...
However, we need Fujiyoushi-sensei to be our medical lab researcher.
What? Because in super medical special zone,
The treatments are restricted to the doctors in that hospital.
By becoming our researcher,
You can save the patient right in front of us.
Of course, it's not a problem to go to help the people in Sakurai Hospital when Fujiyoushi-sensei's assistance is needed there.
Kana can go to elementary school?
You can.
Absolutely? Yes, absolutely.
Thanks God. Yes.
I got it.
This time, Fujiyoushi-sensei
was decided to join with L&P Hospital.
A perfect environment which have both world-class most advanced equipments and super medical special zone,
we will have him to do the research in L&P Hospital.
If we put his research into the practical use,
the patients around the world will be able to be saved.
In other words, selling his research to the world,
bringing enormous profit to L&P.
The most advanced medical research
is also a part of business privilege.
If we can't keep holding the rights of research firmly,
we won't be able to save large numbers of patients with our hands.
Japan's medical care must also have a internationally competitive era.
THE SHOW MUST GO ON!
It's a masterpiece. huh!
What is he thinking? Noguchi.
Well then, reporters who have questions to Fujiyoushi-sensei,
please raise your hands.
What kind of stuff is myocardial sheet?
In the case this time,
since it's a sheet which is cultivated from patient's thigh,
It's officially called myoblast sheets.
And because it's made from patient's own cells,
The risk of rejection, etc. are absolutely none.
It will be nice if he fits the India's water.
It's fine, isn't it?
It doesn't mean that he will go alone..
Ok, please proceed with that amount.
The requirement is that we have to have the priority of product development.
I will continue to infest preferentially from the commodity that leads to the world.
It shouldn't be a bad discussion for you over there also.
Ok. I will prepare the researcher here.
Then, please proceed the discussion immediately.