JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 53, No. 3, May 2024 CONTENTS

Preface

• The Highest Excellence Is like Water　N. Shiiya

Case Reports

• ［Congenital Heart Disease］
• A Case of Infective Endocarditis Treated with Ventricular Septal Defect Closure with the Sandwich Method, Aortic Valve Replacement, and Tricuspid Valve Replacement　H. Sasaki et al.　91
  A Case of Infective Endocarditis Treated with Ventricular Septal Defect Closure with the Sandwich Method, Aortic Valve Replacement, and Tricuspid Valve Replacement
  

  Hanae Sasaki＊	Ryosuke Kowatari＊	Hiroyuki Itaya＊＊
  Kenyu Murata＊	Kazuyuki Daitoku＊	Masahito Minakawa＊

  
  

  (Department of Thoracic and Cardiovascular Surgery, Hirosaki University School of Medicine＊, Hirosaki, Japan, and Department of Cardiothoracic Surgery, Tsugaru General Hospital＊＊, Tsugaru, Japan)
  

  A 74-year-old man was diagnosed with infective endocarditis （IE） involving the aortic and tricuspid valves, ventricular septal defect （VSD）, and complete atrioventricular block. He was admitted to a previous hospital with complaints of fever and neck pain, and he developed complete atrioventricular block during the course of his illness. An echocardiogram revealed severe aortic regurgitation, aortic valve vegetations, and a ventricular septal defect. He was then transferred to our hospital, and he underwent emergent surgery. The aortic valve cusps were calcified and thick, with significant cusp destruction. The vegetations partly extended to the subvalvular area of the right and non-coronary cusp. The vegetations also extended from the atrial septum to the tricuspid valve septal leaflet and perimembranous VSD. Ventricular septal reconstruction using the sandwich technique with two bovine pericardial patches, aortic valve replacement, and tricuspid valve replacement were performed. Postoperatively, he received antibiotic therapy for six weeks and was discharged from our hospital after the implantation of a cardiac resynchronization therapy pacemaker. Echocardiography showed no residual shunts. Our case suggests that the sandwich technique can be a useful method of septal reconstruction for IE with extensive destruction of the ventricular septum.

   

  Jpn. J. Cardiovasc. Surg. 53: 91-94（2024）

  Keywords：Infective endocarditis; ventricular septal defect; aortic valve; tricuspid valve; complete atrioventricular block

  
  
• ［Acquired Cardiovascular Surgery］
• The Efficacy of Continuous Retrograde Cardioplegia for Mitral Annuloplasty in a Case with Total Obstruction at Both Orifices of the Native Coronary Arteries　 S. Sakakibara et al.　95
  The Efficacy of Continuous Retrograde Cardioplegia for Mitral Annuloplasty in a Case with Total Obstruction at Both Orifices of the Native Coronary Arteries
  

  Satoshi Sakakibara＊	Takashi Yamauchi＊	Masaro Nakae＊＊
  Naosumi Sekiya＊＊	Teruya Nakamura＊＊

  
  

  (Department of Cardiovascular Surgery, Higashiosaka City Medical Center＊, Osaka, Japan, and Department of Cardiovascular Surgery, Sakurabashi Watanabe Hospital＊＊, Osaka, Japan)
  

  A 75-year-old male with a previous history of coronary artery bypass grafting （LITA-LAD, RITA-RA-4PD-14PL） was referred to our hospital for congestive heart failure. Cardiac workup revealed severe ischemic mitral regurgitation which required surgical correction. His preoperative coronary arterial computed tomography demonstrated total occlusion of both orifices of the native coronary arteries, and the complete dependence of his myocardial blood supply on the patent bypass grafts without any evidence of ischemia. Therefore, antegrade cardioplegia could not be applied for cardiac protection during the procedure. Continuous retrograde cardioplegia was planned to be applied in a case where both arterial grafts could be dissected and clamped whereas systemic hyperkalemia and mild hypothermia would be applied in case where the clamp would be impossible. Intraoperatively, both arterial grafts could be dissected and clamped and we performed mitral annuloplasty and tricuspid annuloplasty using continuous retrograde cardioplegia. The patient could be weaned off cardiopulmonary bypass without difficulty, and his postoperative course was uneventful. We conclude that continuous retrograde cardioplegia is a safe and viable option, especially when antegrade cardioplegia is not securely delivered due to an occluded coronary ostia.

   

  Jpn. J. Cardiovasc. Surg. 53: 95-99（2024）

  Keywords：native coronary artery occlusion; patent internal thoracic artery; myocardial protection; continuous retrograde cardioplegia

  
  
• A Successful Case of Redo-Tricuspid Valve Replacement for Prosthetic Valve Endocarditis Thirty-Two Years after Single Tricuspid Bioprosthetic Valve Replacement　S. Miura et al.　100
  A Successful Case of Redo-Tricuspid Valve Replacement for Prosthetic Valve Endocarditis Thirty-Two Years after Single Tricuspid Bioprosthetic Valve Replacement
  

  Shuhei Miura＊	Yutaka Iba＊	Kei Mukawa＊
  Keitaro Nakanishi＊	Takakimi Mizuno＊	Ayaka Arihara＊
  Tsuyoshi Shibata＊	Junji Nakazawa＊	Tomohiro Nakajima＊
  Nobuyoshi Kawaharada＊

  
  

  (Department of Cardiovascular Surgery, Sapporo Medical University＊, Sapporo, Japan)
  

  We present a successful case of redo-tricuspid valve replacement for tricuspid prosthetic valve endocarditis. A 78-year-old man who underwent tricuspid bioprosthetic valve replacement for severe tricuspid regurgitation thirty-two years earlier was referred to our institution with persistent high fever and back pain. The blood culture was positive for Streptococcus oralis, and echocardiography revealed a mobile vegetation attached to the tricuspid prosthetic valve with moderate tricuspid regurgitation. A clinical diagnosis of prosthetic valve endocarditis was established. Redo-tricuspid bioprosthetic valve replacement was performed following antibiotics therapy. The patient was discharged on postoperative day 49 after 6 weeks of additional antibiotic treatment, and had no recurrence of infection for 6 months after redo-surgery.

   

  Jpn. J. Cardiovasc. Surg. 53: 100-104（2024）

  Keywords：tricuspid prosthetic valve endocarditis; redo-tricuspid valve replacement

  
  
• Two Cases with Rapidly Developing Malignant Pericardial Mesothelioma　D. Hirayama et al.　105
  Two Cases with Rapidly Developing Malignant Pericardial Mesothelioma
  

  Daiki Hirayama＊	Norihisa Yuge＊	Ryuki Yamada＊
  Mariko Hori＊	Susumu Manabe＊

  
  

  (Department of Cardiac Surgery, International University of Health and Welfare Narita Hospital＊, Narita, Japan)
  

  Case 1: Sixty-seven-year-old male. Presented with exertional dyspnea, raising suspicion for constrictive pericarditis. His condition rapidly progressed to a state of shock, necessitating emergency surgery under percutaneous cardiopulmonary support. Pericardiectomy using the waffle procedure was performed. However, there was limited improvement in hemodynamics, and he died on the 17th postoperative day. Postoperative pathological examination diagnosed epithelioid malignant pericardial mesothelioma. Case 2: Sixty-nine-year-old female. Presented with exertional dyspnea, raising suspicion for constrictive pericarditis. While being transported for surgical intervention, she went into shock, followed by cardiopulmonary resuscitation and initiation of percutaneous cardiopulmonary support. Waiting for the improvement of multiple organ failure, pericardiectomy using the waffle procedure was conducted. However, there was limited improvement in hemodynamics, and she died on the 2nd postoperative day. Postoperative pathological examination diagnosed sarcomatoid malignant pericardial mesothelioma.

   

  Jpn. J. Cardiovasc. Surg. 53: 105-108（2024）

  Keywords：Malignant Pericardial Mesothelioma; pericardial constriction

  
  
• Acute Aortic Regurgitation due to Aortic Dissection Limited to the Sinus of Valsalva, Which Was Found at the Time of Surgery: a Case Report　Y. Nosaka et al.　109
  Acute Aortic Regurgitation due to Aortic Dissection Limited to the Sinus of Valsalva, Which Was Found at the Time of Surgery: a Case Report
  

  Yu Nosaka＊	Hironari No＊	Hiroki Kato＊

  
  

  (Ishikawa Prefectural Central Hospital＊, Kanagawa, Japan)
  

  Aortic dissection is one cause of acute aortic regurgitation, and transthoracic echocardiography and computed tomography are useful for diagnosis. We report a case of intraoperatively discovered acute aortic regurgitation caused by aortic dissection limited to the sinus of Valsalva. The patient was a 71-year-old man who regularly visited his local doctor for hypertension and diabetes mellitus. He visited the doctor with a week-long history of cough and dyspnea, and was referred to our hospital due to acute congestive heart failure. We diagnosed severe acute aortic regurgitation as the cause of the heart failure, but the aortic root dissection was not detected by transthoracic echocardiography or plain computed tomography. Since his heart failure progressively worsened even with intensive medical therapy, urgent surgery was decided on the 6th day after hospitalization. Intraoperatively, we noted that the aortic dissection was limited to the sinus of Valsalva, and had induced aortic regurgitation due to dissected and separated aortic commissure. We changed the surgical procedure from aortic valve replacement to the Bentall procedure （Piehler method）. Postoperatively, the patient was intubated for 7 days and stayed in the ICU for 14 days due to treatment for pneumothorax and organizing pneumonia. He was successfully transferred to a rehabilitation hospital on the 35th postoperative day. Acute aortic regurgitation caused by aortic dissection limited to the sinus of Valsalva is rare, so we report the case based on literature reviews and as a heart team.

   

  Jpn. J. Cardiovasc. Surg. 53: 109-113（2024）

  Keywords：acute aortic regurgitation; aortic dissection limited to the sinus of Valsalva; transesophageal echocardiography; cardiac computed tomography

  
  
• A Case of Aortic Valve Replacement with Valve Ring Enlargement for Future TAV in SAV　M. Nakahara et al.　114
  A Case of Aortic Valve Replacement with Valve Ring Enlargement for Future TAV in SAV
  

  Mitsukuni Nakahara＊	Kenji Iino＊	Yoshitaka Yamamoto＊
  Masaki Kitazawa＊	Hiroki Nakabori＊	Hideyasu Ueda＊
  Yukiko Yamada＊	Akira Murata＊	Hirofumi Takemura＊

  
  

  (Department of Cardiovascular Surgery, Kanazawa University Hospital＊, Kanazawa, Japan)
  

  When performing aortic valve replacement in young patients, mechanical valves are recommended due to their durability. However, because mechanical valves require lifelong use of warfarin and carry risks such as easy bleeding, bioprosthetic valve replacement may be performed in some cases even in young patients. In this report, we describe a case of a patient who underwent bioprosthetic aortic valve replacement with aortic annular enlargement in anticipation of TAV in SAV and had a good postoperative course. The patient is a 51-year-old male. He was referred to our hospital for surgical treatment of severe aortic stenosis. The patient strongly preferred a bioprosthetic valve due to the disadvantage of taking warfarin. Therefore, we considered the possibility of TAV in SAV due to his young age, and decided to perform aortic annular enlargement if necessary. Intraoperatively, after resection and decalcification of the valve, a sizer was inserted, but the 19 mm sizer could not pass through, so we decided to perform aortic annular enlargement. Aortic annular enlargement was performed by suturing a Dacron patch and implantation of a 23 mm bioprosthetic valve. The patient had no major postoperative problems and was discharged home on the 14th day after surgery. In order to avoid PPM in the future when TAVI is performed, aortic annular enlargement should be considered in young patients undergoing aortic valve replacement using a bioprosthetic valve if TAV in SAV is considered to be difficult.

   

  Jpn. J. Cardiovasc. Surg. 53: 114-118（2024）

  Keywords： aortic stenosis; valve ring enlargement; TAV in SAV

  
  
• A Case of Ross Procedure for Aortic Regurgitation due to Prolapse of a Right Coronary Cusp Caused by Natural Closure of Ventricular Septal Defect　N. Yoshitani et al.　119
  A Case of Ross Procedure for Aortic Regurgitation due to Prolapse of a Right Coronary Cusp Caused by Natural Closure of Ventricular Septal Defect
  

  Nobuyuki Yoshitani＊	Hiroyuki Hayashi＊	Ahn Kun Tae＊
  Takuya Misato＊	Taro Hayashi＊	Yutaka Okita＊

  
  

  (Department of Cardiovascular Surgery, Akashi Medical Center＊, Akashi, Japan, and Department of Cardiovascular Surgery, Cardio-Aortic Center, Takatsuki General Hospital＊＊, Takatsuki, Japan)
  

  A 44-year-old man had been pointed out to have a heart murmur during his elementary school days. He came to us complaining of chest pain and palpitation. He was diagnosed to have severe aortic regurgitation caused by prolapse of the right coronary cusp, and the left ventricular function was depressed. At surgery, the aortic valve was repaired with the RCC resuspension technique, but regurgitation was not controlled because the RCC annulus was retracted by natural supracristal closure of the ventricular septal defect. We proceeded to the Ross procedure. A pulmonary autograft was harvested and sewed in the aortic annulus. The right ventricular outflow tract was reconstructed using a stentless bioprosthetic valve with glutaraldehyde-treated bovine pericardium. He was discharged after a straightforward postoperative course.

   

  Jpn. J. Cardiovasc. Surg. 53: 119-122（2024）

  Keywords：ventricular septal defect; aortic regurgitation; ross procedure

  
  
• ［Aortic Disease］
• A Case of Acute Type A Aortic Dissection with Malperfusion of the LMT with a History of Open-Heart Surgery　H. Otani et al.　123
  A Case of Acute Type A Aortic Dissection with Malperfusion of the LMT with a History of Open-Heart Surgery
  

  Hiroe Otani＊	Hiroyuki Watanabe＊	Masayoshi Otsu＊
  Takuto Maruyama＊

  
  

  (Japanese Red Cross Narita Hospital Cardiovascular Surgery＊, Narita, Japan)
  

  A 75-year-old woman was referred to our hospital with sudden onset of chest and back pain. She showed ventricular fibrillation during transportation and shock vitals on arrival at the hospital. An electrocardiogram （ECG） showed ST segment elevation in aVR, and emergency coronary angiography （CAG） was performed. CAG revealed malperfusion of the left main coronary artery （LMT） due to type A aortic dissection. Emergency percutaneous coronary intervention （PCI） was performed and coronary revascularization was achieved. Strict blood pressure management was performed in the intensive care unit. She underwent ascending aortic replacement two days after onset of the disease. Although she required long-term postoperative ventilator management, she did not develop low output syndrome （LOS）. In this case, emergency PCI minimized myocardial ischemia, and LOS could have been avoided by waiting for circulation to recover and then performing surgery.

   

  Jpn. J. Cardiovasc. Surg. 53: 123-126（2024）

  Keywords：left main coronary trunk; acute aortic dissection

  
  
• Acute Aortic Dissection Managed with Nafamostat for Heparin Resistance in the Presence of DOAC Reversal Agent: a Case Report　K. Morimoto et al.　127
  Acute Aortic Dissection Managed with Nafamostat for Heparin Resistance in the Presence of DOAC Reversal Agent: a Case Report
  

  Kenichi Morimoto＊	Shigeto Miyasaka＊	Rikuto Nii＊
  Yosuke Ikeda＊

  
  

  (Department of Cardiovascular Surgery, Tottori Prefectural Central Hospital＊, Tottori, Japan)
  

  The patient, a female in her 60s, was under anticoagulant therapy with direct oral anticoagulant (DOAC） for persistent atrial fibrillation. She suddenly presented with chest pain, prompting her emergency admission to our medical facility. Subsequently, she received a diagnosis of acute aortic dissection （Stanford A） and was referred to our department for urgent surgical intervention. The administration of Andexanet Alfa was initiated in the emergency department due to the markedly elevated risk of life-threatening hemorrhage associated with DOAC medications. Surgery was approached through a median sternotomy, and 20,000 units of unfractionated heparin were administered intravenously during cardiopulmonary bypass （CPB） preparation. However, the activated clotting time （ACT） exhibited suboptimal extension at 181 s （pre-heparin ACT: 124 s）, necessitating supplementary heparin infusion. This resulted in the cumulative administration of 80,000 U of heparin before achieving an ACT exceeding 400 s. Suspecting heparin resistance, we maintained an ACT greater than 400 s during CPB through the continuous administration of nafamostat within the CPB circuit. Subsequently, we performed graft replacement of the ascending aorta, weaning from the CPB was smooth, hemostasis was good, and the operation was completed. The patient’s postoperative recovery remained uneventful, leading to her discharge on the 11th day following the surgery. Notably, there were no instances of major bleeding or thromboembolic events during her hospitalization. Preoperative oral DOAC therapy presents a critical and potentially life-threatening concern due to its association with heightened intraoperative and postoperative bleeding risks. Currently, a Factor Xa inhibitor reversal agent, Andexanet Alfa （Ondexa®），is available and expected to contribute to the treatment of critical bleeding in patients taking DOAC. However, further research is warranted to accumulate knowledge regarding its efficacy and optimal utilization. In this case, we present an instance of acute aortic dissection with heparin resistance following the preoperative administration of a DOAC antagonist, contributing to the existing literature on this matter.

   

  Jpn. J. Cardiovasc. Surg. 53: 127-130（2024）

  Keywords：DOAC; Andexanet Alfa; heparin resistance; acute aortic dissection

  
  
• Total Arch Replacement for Aortic Arch Thrombosis Combined with Severe Mitral Regurgitation　M. Saitoh et al.　131
  Total Arch Replacement for Aortic Arch Thrombosis Combined with Severe Mitral Regurgitation
  

  Masato Saitoh＊	Takuma Yamasaki＊	Tomoaki Tanabe＊
  Shuichi Tochigi＊	Shoh Tatebe＊＊	Imun Tei＊

  
  

  (Department of Cardiovascular Surgery＊, Ayase Heart Hospital＊, Ayase, Japan, and Department of Cardiovascular Surgery, Ayase Heart Rehabilitation Hospital＊＊, Ayase, Japan)
  

  A 74-year-old male with exertional breathlessness was referred to our hospital by his general physician. Echocardiography revealed severe mitral regurgitation. An aortic and coronary computed tomography scan revealed aortic arch thrombosis and coronary artery stenosis in the left anterior descending （LAD） artery. In consideration of the risk of embolization, the patient underwent emergency surgery on the same day. The surgical procedure involved the replacement of the aortic arch with a fenestrated frozen elephant trunk, mitral valvuloplasty, and coronary artery bypass graft for the LAD artery. Blood tests revealed no underlying coagulopathy. The patient did not develop any postoperative complications. He was discharged home on his own on postoperative day 19. One year after the surgery, no recurrence of thrombosis or heart failure was observed. Severe mitral regurgitation complicated with intraaortic thrombosis is rare. This case report indicates that intraaortic thrombosis can occur even in patients without any underlying blood coagulation abnormalities. We report this case with a review of the literature.

   

  Jpn. J. Cardiovasc. Surg. 53: 131-135（2024）

  Keywords：aortic thrombus; mitral regurgitation; fenestrated frozen elephant trunk technique

  
  
• A Case of Survival after Thoracic Endovascular Aortic Repair for Descending Thoracic Aortic Aneurysm Rupture and Aortoesophageal Fistula without Esophagectomy　N. Tominaga et al.　136
  A Case of Survival after Thoracic Endovascular Aortic Repair for Descending Thoracic Aortic Aneurysm Rupture and Aortoesophageal Fistula without Esophagectomy
  

  Norihisa Tominaga＊	Daisuke Machida＊	Norio Yukawa＊
  Munetaka Masuda＊＊	Shinichi Suzuki＊

  
  

  (Department of Surgery・Cardiovascular Surgery, Yokohama City University Hospital＊, Yokohama, Japan, and Department of Cardiovascular Surgery, Fukuoka Wajiro Hospital＊＊, Fukuoka, Japan)
  

  The patient was an 82-year-old woman. For dysphagia scrutiny, upper gastrointestinal endoscopy and biopsy of a submucosal tumor of the midthoracic esophagus were performed. The patient was urgently admitted to the Department of Gastroenterology for examination and treatment. After admission, enhanced CT showed a descending thoracic aortic aneurysm （DTA） pressing on the esophagus. On the third day of hospitalization, the patient suffered massive hematemesis and went into shock, and emergency thoracic endovascular aortic repair （TEVAR） was performed with resuscitation based on the diagnosis of esophageal perforation of the DTA. The patient was weaned from the ventilator by tracheotomy without cerebrospinal complications and left the intensive care unit on the seventh postoperative day. One month after surgery, a CT scan showed that the DTA had almost disappeared and that the esophageal compression had been released. The patient was managed with antibacterial therapy and nutritional support other than oral intake and was discharged home 7 months after surgery without stent graft infection or mediastinitis. The usefulness of TEVAR for ruptured descending thoracic aortic aneurysms has been reported in many cases. However, in patients with an aortoesophageal fistula （AEF），esophagectomy is required after TEVAR to control infection, and the mortality rate of this disease is high. We report a case in which infection were controlled by antibacterial therapy and nutritional management other than oral intake after TEVAR and the patient survived.

   

  Jpn. J. Cardiovasc. Surg. 53: 136-142（2024）

  Keywords： descending thoracic aortic aneurysm （DTA）; aortoesophageal fistula （AEF）; thoracic endovascular aortic repair （TEVAR）

  
  
• A Case of Open Graft Replacement for Abdominal Stent Graft Infection Caused by Cholecystitis　H. Otani et al.　143
  A Case of Open Graft Replacement for Abdominal Stent Graft Infection Caused by Cholecystitis
  

  Hiroe Otani＊	Hiroyuki Watanabe＊	Masayoshi Otsu＊
  Takuto Maruyama＊

  
  

  (Cardiovascular Surgery, Japanese Red Cross Narita Hospital＊, Narita, Japan)
  

  A 67-year-old man underwent endovascular aneurysmal repair for an abdominal aneurysm at another hospital about a year earlier. He presented to us with complaints of abdominal pain with an accompanying fever. Contrast-enhanced CT revealed a stent graft thrombus, with discontinuity of the aneurysmal wall, and a mass in the left retroperitoneal space, suggesting stent graft infection. The patient’s fever initially subsided with antibiotic treatment, but soon recurred. Plain CT revealed an enlarged left retroperitoneal mass, which was determined to be a contained aneurysmal rupture. The stent graft was surgically removed urgently without incident and, upon examination of the removed stent graft, it was noted that there was a section of yellowish-white tissue attached to the stent graft and definitive evidence of infection was apparent. Thorough debridement of the aneurysmal wall was performed, leaving a segment of the posterior wall intact. In-situ reconstruction was carried out using a Gelsoft graft soaked in rifampicin. There was evidence of purulent pus outflow and cholecystitis during the ablation procedure of the hepatic flexure for omental filling. Post cholecystectomy, the reconstructed vascular graft was covered with omentum. A bacterium, Bacteroides thetaiotaomicron, was detected in the pus, bile, and on the stent graft removed during the surgical procedure. Subsequently, a diagnosis of hematogenous stent graft infection during the course of acute cholecystitis was made. The postoperative course of the patient was uneventful, with no recurrence of infection observed in the 3 months following surgical intervention.

   

  Jpn. J. Cardiovasc. Surg. 53: 143-146（2024）

  Keywords：stent graft infection; EVAR; open graft replacement

  
  
• Type A Acute Aortic Dissection Complicated with Rupture of the External Iliac Artery　Y. Hari et al.　147
  Type A Acute Aortic Dissection Complicated with Rupture of the External Iliac Artery
  

  Yosuke Hari＊	Noritsugu Naito＊	Yuhi Nakamura＊
  Hisaya Mori＊	Hisato Takagi＊

  
  

  (Department of Cardiovascular Surgery, Shizuoka Medical Center＊, Shizuoka, Japan)
  

  A 67-year-old man suffered sudden chest pain. Computed tomography with contrast medium revealed dissection from the ascending aorta to the bilateral iliac arteries and hematoma around the left external iliac artery. Type A acute aortic dissection complicated with rupture of the left external iliac artery was diagnosed. Urgent endovascular repair（stent-graft implantation）was first performed for the arterial rupture more critical than the aortic dissection. On the next day after satisfactory hemostasis and hemodynamical stabilization, semi-urgent ascending aortic replacement was achieved, and the patient survived. Acute aortic dissection complicated with rupture of the aortic branch was extremely rare, and only 5 cases have been reported in the English literature.

   

  Jpn. J. Cardiovasc. Surg. 53: 147-150（2024）

  Keywords：rupture of the external iliac artery; type A acute aortic dissection; intravascular repair

  
  
• Urgent Thoracic Endovascular Aortic Repair for Retrograde Type A Acute Aortic Dissection with a Patent Ascending Aortic False Lumen　Y. Hari et al.　151
  Urgent Thoracic Endovascular Aortic Repair for Retrograde Type A Acute Aortic Dissection with a Patent Ascending Aortic False Lumen
  

  Yosuke Hari＊	Noritsugu Naito＊	Yuhi Nakamura＊
  isaya Mori＊	Hisato Takagi＊

  
  

  (Department of Cardiovascular Surgery, Shizuoka Medical Center＊, Shizuoka, Japan)
  

  We report a 49-year-old man with retrograde type A acute aortic dissection with patent false lumen in the ascending aorta. The patient successfully underwent urgent thoracic endovascular repair （TEVAR） to cover the primary entry on the onset （admission） day. The false lumen from the ascending aorta to the proximal descending thoracic aorta was completely thrombosed, gradually shrank, and finally disappeared. In conclusion, TEVAR for retrograde type A acute aortic dissection with a patent ascending false lumen is far less invasive than aortic replacement （with cardiopulmonary bypass, cardiac arrest, and circulatory arrest） and may be useful in selected patients with a primary entry located at least approximately 2 cm distal to the origin of the left subclavian artery.

   

  Jpn. J. Cardiovasc. Surg. 53: 151-154（2024）

  Keywords：retrograde type A acute aortic dissection; patent false lumen; thoracic endovascular aortic repair

  
  

Progress in Cardiovascular Surgery (2023)

• Current Trends in the Surgical Treatment of Advanced Heart Failure in Japan　H. Kohno and G. Matsumiya　155
• Update of 2023 in Peripheral Artery Disease　T. Kudo　158

U-40

• U-40 Column
• Let’s Learn NOTSS !!　D. Takagi et al. 　U1
  Let’s Learn NOTSS !!
  

  Daichi Takagi＊	Kenji Namiguchi	Yoshinori Inoue
  Satoshi Hoshino	Kenichiro Takahashi

  
  

  (Department of Cardiovascular Surgery, Akita University＊, Akita, Japan）
  

  Many cardiovascular surgeons are well aware of the importance of non-technical skills but don’t know what behaviors with high quality non-technical skills are in the operating room. The Non-Technical Skills for Surgeons（NOTSS）system was developed to be used as a debriefing tool for supervisors to assess the non-technical skills of trainee surgeons and provide feedback immediately after surgery. The NOTSS system has the four categories containing three elements respectively, with "good behavior" and "bad behavior" indicated for each element. The purpose of this column is to introduce the NOTSS and to provide an opportunity to think about how cardiovascular surgeons should behave in the operating room.

  Keywords：U-40; NOTSS; non-technical skills

  
  

Editor’s Post Script

• K. Miyaji

Development of a Prognostic Model for Mid-Term Outcomes of Infra-Popliteal Artery Bypass