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104cular ultrasound, fractional flow reserve analysis, and cardiac nuclear medicine to select the most appropriate treatment and graft for patients24). Although there are no long-term results published yet, we believe that the usefulness of these methods will become apparent in the future.Since 2010, the problem in Japan has been the aging of patients undergoing surgery and the increase in complex systemic conditions such as chronic dialysis, cerebrovascular disease, and malignant complications. Therefore, we need to reduce postoperative complications, life expec-tancy, and graft patency rates.Approaches to the Treatment of Coronary Artery Disease at Juntendo UniversitySince 1980, coronary artery bypass surgery has been actively performed for ischemic heart disease at Juntendo University. Since the establishment of the Department of Cardiovascular Surgery in 2002, the number of coronary artery surgery cases has increased, and in tandem, the number of associated complications. In particular, the number of opera-tions for aortic valve disease is increasing (Figure 3). From 2000 to 2020, the average age of patients who underwent primary isolated CABG had increased from 66 years to 69 years. Furthermore, the number of patients on dialysis and those with cerebral or malignant disease had increased, accounting for Figure 3　Changes in the Number of Surgeries for Ischemic Heart Disease at Juntendo UniversityCABG: coronary artery bypass graftingAVR: aortic valve replacementLV plasty: left ventricular plasty14%, 16%, and 17% of all patients, respectively (Figure 4).We actively performed off-pump coronary artery bypass grafting (OPCAB) to make CABG less invasive and accommodated the increasing number of such high-risk cases. However, OPCAB is tech-nically difficult, and the CORONARY trial reports in 2012 and 2013 did not reveal its superiority over conventional cardiopulmonary surgery25, 26). A meta- analysis by Deppe et al. (2016) showed that OPCAB was superior in most categories, including mortality, myocardial infarction, stroke, renal failure, infec-tion, and bleeding; however, the large variation of revascularization rate and technical differences among surgeons were major concerns27). Conse-quently, OPCAB has not become popular in Europe and the United States; however, OPCAB use in Japan comprises up to 65% of all isolated CABG procedures due to its active promotion by leading institutions such as Juntendo University (Table 1).Since 2002, we have performed OPCAB in 98% of our patients at Juntendo. The average number of bypasses exceeded three, and multiple arterial grafts were used in over 70% of the cases (Table 1). In 2018, the hospital mortality rates were 2.5% in Japan28), and the American Association of Thoracic Surgeons reported a rate of 2.2%29). In contrast, Juntendo has maintained a 1% in-hospital mortality rate since 1984. Furthermore, neurological compli-OthersCABG+LV plastyCABG+AortaCABG+other valveCABG+AVRRedo CABGIsolated CABG