JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 54, No. 1, January 2025 CONTENTS

Preface

• The Way Cardiovascular Surgeons Work: My Perspective　S. Oda

Case Reports

• ［Acquired Cardiovascular Surgery］
• A Case of Surgical Repair for Left Ventricular Septal Perforation with Septal Dissection due to Acute Myocardial Infarction　T. Shimada et al.　1
  A Case of Surgical Repair for Left Ventricular Septal Perforation with Septal Dissection due to Acute Myocardial Infarction
  

  Takashi Shimada＊	Yuichi Tasaki＊	Shirou Hazama＊
  Takashi Miura＊＊

  
  

  (Department of Cardiovascular Surgery, Sasebo General Hospital＊, Sasebo, Japan, and Department of Cardiovascular Surgery, Nagasaki University Hospital＊＊, Nagasaki, Japan)
  

  The patient is a 71-year-old man who developed a ventricular septal perforation （VSP） with septal dissection after acute myocardial infarction（AMI）. Heart failure symptoms were stabilized with intra-aortic balloon pumping and diuretics, and the VSP was closed via a left ventriculotomy approach on day 23 after AMI and day 12 after identification of the VSP. The right ventricular perforation was closed with a single patch of bovine pericardium, and the left ventricular perforation was closed with a double patch using the infarct exclusion technique. The septal dissection cavity was closed with BioGlue surgical adhesive （Artivion, Inc., Kennesaw, GA, USA）. The patientʼs postoperative course was uneventful and he was discharged home on postoperative day 36. His NYHA functional class was I at 1 year and 6 months after surgery.

   

  Jpn. J. Cardiovasc. Surg. 54: 1-4（2025）

  Keywords：inferior myocardial infarction; ventricular septal dissection; ventricular septal perforation

  
  
• A Case of Double Patch Closure for Left Ventricular Pseudoaneurysm after yocardial Infarction　H. Niwano et al.　5
  A Case of Double Patch Closure for Left Ventricular Pseudoaneurysm after Myocardial Infarction
  

  Haruki Niwano	Yuji Naito＊	Hiroshi Sugiki＊
  Tatsuya Murakami＊

  
  

  （Thoracic Surgery, Asahikawa City Hospital＊, Asahikawa, Japan）
  

  A 67-year-old male was referred to our department for surgical treatment of a left ventricular mass after myocardial infarction. The left ventricular aneurysm was 50×20 mm and the papillary muscles were close to each other. To avoid displacement of the papillary muscles and its effect on the mitral valve, a double-patch closure was performed. A bovine pericardial patch was placed on the endocardial side and a Dacron patch on the epicardial side, and fibrin glue was injected between the two patches. Mitral valvuloplasty and coronary artery bypass grafting were also performed, and the patient had an uncomplicated postoperative course and was discharged home on the 27th postoperative day. Histopathological findings showed no myocardial cells in the wall of the mass, and a diagnosis of pseudoaneurysm was made. Double-patch closure is considered effective for left ventricular masses with a large opening and close proximity to the papillary muscle, as in this case.

   

  Jpn. J. Cardiovasc. Surg. 54: 5-8（2025）

  Keywords：double patch closure; left ventricular pseudo-aneurysm; myocardial infarction

  
  
• A Patient with MCTD-Complicated Aortic Stenosis Who Developed Severe Thrombocytopenia and Multiple Thromboses after Valve Replacement　T. Haraguchi et al.　9
  A Patient with MCTD-Complicated Aortic Stenosis Who Developed Severe Thrombocytopenia and Multiple Thromboses after Valve Replacement
  

  Tomonori Haraguchi＊	Rei Noda＊

  
  

  (Department of Cardiovascular Surgery, Ako City Hospital＊, Ako, Japan)
  

  The patient was a 70-year-old female who had been diagnosed with Mixed Connective Tissue Disease （MCTD） and treated with oral steroids at another clinic for the previous 7 years. As she developed exercise-induced respiratory discomfort and paroxysmal atrial fibrillation, and received a diagnosis of aortic stenosis and angina pectoris, aortic valve replacement using a biological valve and coronary artery bypass to LAD were performed. An intra-aortic balloon pump （IABP） was placed due to LOS associated with acute thrombocytopenia and bleeding tendency during the operation. Although postoperative hemodynamics were stable, an infiltrative shadow was observed in the entire right lung. On Day 4, remarkable thrombocytopenia reappeared. On Day 5, the IABP was removed and the anticoagulant changed from heparin to nafamostat; however, thrombocytopenia continued. On Day 9, CAG was performed, and complete obstruction was detected at the proximal part of the circumflex branch, which was not observed before the operation. Hence, emergency PCI was performed to re-insert the IABP. Aggravation of thrombocytopenia was observed along with progressive necrosis of fingertips and oral cavity as well as mucous-bloody stool. On day 24, the patientʼs condition was complicated by subarachnoid hemorrhage of unknown cause and she died on Day 34 due to extensive colonic necrosis.

   

  Jpn. J. Cardiovasc. Surg. 54: 9-13（2025）

  Keywords：Mixed Connective Tissue Disease （MCTD）; aortic valve replacement; thrombocytopenia

  
  
• Coronary Artery Bypass Grafting and Thrombectomy for Multiple Spontaneous Coronary Artery Dissection　R. Tsuruhara et al.　14
  Coronary Artery Bypass Grafting and Thrombectomy for Multiple Spontaneous Coronary Artery Dissection
  

  Ryoichi Tsuruhara＊	Yukihiro Hayatsu＊	Masaaki Naganuma＊
  Naoya Terao＊	Hayate Nomura＊	Kazuhiro Yamaya＊
  Masaki Hata＊

  
  

  (Department of Cardiovascular Surgery, Sendai Kosei Hospital＊, Sendai, Japan)
  

  A 45-year-old male presented to a hospital for shortness of breath and palpitations, and an electrocardiogram abnormality was identified. Coronary angiography showed multiple spontaneous coronary artery dissection （SCAD） on the left anterior descending artery （LAD） and the right coronary artery （RCA）. Optical coherence tomography showed the LAD had two lumens, and the RCA had multiple lumens by SCAD. Furthermore, computed tomography depicted a bulky thrombus on the left ventricular apex. All lesions were revascularized with arterial grafts, and the concomitant thrombectomy was performed for the thrombus on the apex. The coronary arteries were clearly dissected, and the anastomosis was made to what appeared to be a true lumen based on various intraoperative assessments. The flow pattern and flow volume through the grafts were satisfactory using the ultrasound Doppler method. The patientʼs postoperative course was uneventful, and he was discharged on postoperative day 22. All grafts have been patent, and the cardiac function has remained improved for 2.5 years of follow-up in our outpatient clinic.

   

  Jpn. J. Cardiovasc. Surg. 54: 14-17（2025）

  Keywords：spontaneous coronary artery dissection; coronary artery bypass grafting; left ventricular thrombus

  
  
• Surgery for Partial Atrioventricular Septal Defect in a Septuagenarian Patient　Y. Nishimoto et al.　18
  Surgery for Partial Atrioventricular Septal Defect in a Septuagenarian Patient
  

  Yukihiro Nishimoto＊	Akimasa Morisaki＊	Yosuke Takahashi＊
  Yoshito Sakon＊	Kenta Nishiya＊	Goki Inno＊
  Kazuki Noda＊	Munehide Nagao＊	Toshihiko Shibata＊

  
  

  (Department of Cardiovascular Surgery, Osaka Metropolitan University Graduate School of Medicine＊, Osaka, Japan)
  

  Surgery for an atrioventricular septal defect （AVSD） is rare in septuagenarians. This is the case of a 75-year-old man with partial AVSD. He developed dyspnea on exertion. Detail examinations revealed partial AVSD, severe left atrioventricular valve （LAVV） regurgitation, severe right atrioventricular valve （RAVV） regurgitation, persistent atrial fibrillation, and coronary artery stenosis, which required surgical intervention. Subsequently, we performed ostium primum-type atrial septal defect closure using an autologous pericardium patch, LAVV replacement with a bioprosthetic valve, RAVV repair without annuloplasty, a modified Maze IV procedure, left atrial appendage closure, and coronary artery bypass grafting. Although LAVV repair for LAVV regurgitation was initially performed, it was converted to LAVV replacement because the repair could not control the regurgitation due to advanced degenerative changes with the thickening of the leaflets. The patient was discharged on the 15th postoperative day uneventfully. One and a half years after surgery, he had neither cardiovascular events nor arrhythmias.

   

  Jpn. J. Cardiovasc. Surg. 54: 18-22（2025）

  Keywords：adult congenital heart disease; atrioventricular septum defect

  
  
• Two Cases of Surgical Re-Intervention for Mitral Regurgitation after MitraClip　M. Fusegawa et al.　23
  Two Cases of Surgical Re-Intervention for Mitral Regurgitation after MitraClip
  

  Masato Fusegawa＊	Naritomo Nishioka＊	Keita Sasaki＊
  Shuhei Miura＊	Takahiko Masuda＊	Ryushi Maruyama＊
  Yoshihiko Kurimoto＊	Shuichi Naraoka＊

  
  

  （Department of Cardiovascular Surgery, Teine Keijinkai Hospital＊, Sapporo, Japan）
  

  In recent years, the number of MitraClip procedures has increased among high-risk patients for open-heart surgery with mitral regurgitation. However, surgical re-intervention is sometimes required after a MitraClip procedure, and this re-intervention carries high risks considering the patients’ backgrounds. We report on two cases of surgical re-intervention after MitraClip procedures. Case 1: An 82-year-old man experienced repeated heart failure due to severe mitral regurgitation （MR） caused by chronic atrial fibrillation. He underwent the MitraClip procedure because of his advanced age and frailty. However, his heart failure became uncontrollable due to an acute exacerbation of MR caused by Clip detachment. He underwent mitral valve replacement （MVR） 10 days after the MitraClip procedure. Case 2: A 72-year-old man experienced heart failure due to severe ischemic MR. The MitraClip procedure was performed because of hemorrhagic cerebral infarction and emphysema. However, two years after the MitraClip procedure, his condition was worsened due to MR and mitral stenosis. He eventually underwent MVR. If surgical re-intervention is required after a MitraClip procedure, open-heart surgery such as valve replacement is essential. When performing valve replacement surgery, it is considered important to preserve the subvalvular apparatus as much as possible to prevent complications.

   

  Jpn. J. Cardiovasc. Surg. 54: 23-26（2025）

  Keywords：MitraClip; surgical re-intervention; MVR

  
  
• ［Aortic Disease］
• Total Arch Replacement for a Patient with Cold Agglutinin　Y. Nakao et al.　27
  Total Arch Replacement for a Patient with Cold Agglutinin
  

  Yuko Nakao＊	Kazuki Hisatomi＊	Yutaro Ryu＊
  Masayuki Takura＊	Syunsuke Taguchi＊	Hiromitsu Teratani＊
  Shun Nakaji＊	Ichiro Matsumaru＊	Takashi Miura＊

  
  

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

  A 74-year-old woman was scheduled for total arch replacement because of an enlarging thoracic aortic aneurysm in the aortic arch. Her preoperative blood test showed an elevated cold agglutinin with a titre of 2,048. There was concern about hemagglutination during hypothermia and hemolysis when returning to natural temperature under hypothermic circulatory arrest. We usually use moderate hypothermia （a minimum rectal temperature of 27℃） with circulatory arrest during total arch replacement. A cooling test was performed with her blood, which found no coagulation reaction in vitro at 25℃. There was a possibility that the total arch replacement would be carried out under moderate hypothermia, but it was by no means certain. After discussing the case with the hematologist, anesthetist, and clinical engineer, we decided on a minimum temperature of 30℃ during circulatory arrest because hemagglutination or hemolysis can become an issue in cardiopulmonary bypass. Coronary perfusion was maintained by infusing blood cardioplegia at 30℃ every 30 min. The intra-aortic occlusion balloon was inflated in the descending aorta, and perfusion of the spinal cord and lower body was initiated via the left femoral artery during circulatory arrest. Total selective cerebral perfusion flow was maintained at 1.5 times normal （20 ml/kg/min）. There was no hemagglutination or hemolysis during the operation and no neurological complications in the postoperative period. For patients with cold agglutinin, individual cardiopulmonary bypass planning is necessary, depending on the severity of the condition and operative method.

   

  Jpn. J. Cardiovasc. Surg. 54: 27-30（2025）

  Keywords：cold agglutinins; aortic arch aneurysm; total arch replacement; spinal cord protection; cardioplegia

  
  
• A Case of a 4-Stage Operations, Including TEVAR through the Descending Aorta as an Access Route, for Multiple Aortic Aneurysms Complicated by Severe COPD　 T. Sano et al.　31
  A Case of a 4-Stage Operations, Including TEVAR through the Descending Aorta as an Access Route, for Multiple Aortic Aneurysms Complicated by Severe COPD
  

  Tomonori Sano＊	Keiji Iwata＊	Takanori Shibukawa＊
  Yumi Kakizawa＊

  
  

  (Department of Cardiovascular Surgery, Sakai City Medical Center＊, Sakai, Japan)
  

  We report a case of performing a 4-stage operations, including TEVAR through the descending aorta as an access route, for multiple aortic aneurysms complicated by severe COPD. The patient was a 71-year-old woman. A chest X-ray suggested a thoracic aortic aneurysm （TAA）. CT scans revealed significant aortic tortuosity and six aortic aneurysms, including a TAA with a maximum diameter of 65 mm. However, due to severe mixed ventilatory impairment with an FEV1 of 39% and a %VC of 64%, a multi-stage surgery including TEVAR was chosen from the perspective of surgical tolerance. Additionally, due to severe calcification and stenosis extending from both iliac arteries to the femoral arteries and significant aortic tortuosity, careful planning for endovascular access was necessary. In the first stage, TEVAR was performed through the descending aorta as the access route for the TAA. In the second stage, a prosthetic graft replacement （abdominal four-branched reconstruction） was performed for the thoracoabdominal aortic aneurysm. In the third stage, TEVAR was performed using a prosthetic graft branch as the access route for the remaining TAA. In the fourth stage, additional TEVAR was performed for the endoleak, and EVAR was performed for the abdominal aortic aneurysm and common iliac artery aneurysm, completing the treatment in four stages. By carefully designing treatment strategies, such as access routes for endovascular stent-graft insertion with a focus on minimal invasiveness, severe postoperative complications, including respiratory issues, were successfully avoided.

   

  Jpn. J. Cardiovasc. Surg. 54: 31-36（2025）

  Keywords：multiple aortic aneurysms; multistage surgery; descending aortic approach; TEVAR; COPD

  
  
• Debranching and Endovascular Repair of Distal Anastomotic Leak after Ascending Aorta Replacement with Preoperatively Devised, Fenestrated and Branched Stent Grafts (Surgeon-Modified Fenestrated and Retrograde Branched Technique)　S. Kamihira et al.　37
  Debranching and Endovascular Repair of Distal Anastomotic Leak after Ascending Aorta Replacement with Preoperatively Devised, Fenestrated and Branched Stent Grafts（Surgeon-Modified Fenestrated and Retrograde Branched Technique）
  

  Satoshi Kamihira*	Tomoki Hanada*	Kazuma Kanetsuki*
  Masanobu Yamauchi*

  
  

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

  A 79-year-old male who underwent emergency ascending replacement for type A acute aortic dissection 2 months earlier. Postoperative CT showed a Distal anastomotic leak and blood flow from multiple entries below the descending aorta into the false lumen, resulting in poor thrombosis and rapid aortic diameter enlargement, requiring additional therapeutic intervention at an early stage. It was difficult to perform total aortic arch replacement or hybrid arch repair with a commercially available device. After ethical approval had been obtained from the institutional review board, a commercially available stent graft （Relay Plus®） was fenestrated with a 12-mm hole. Under general anesthesia, bypass grafting was performed between the bilateral axillary arteries and the left common carotid artery with a T-shaped ring supported e-PTFE prosthesis. The fenestrated stent graft was advanced through the left femoral artery and deployed with the device fenestration located at the bifurcation of the brachiocephalic artery. Then, a branched stent graft was deployed through the right common carotid artery in a retrograde manner between the brachiocephalic artery and the ascending aorta through the fenestration to complete the procedure. The patient had an uneventful postoperative course. Six months postoperative CT showed only a small, dissected lumen in the aorta around the left renal artery, and the dissected lumen had regressed to a thrombosed lumen. The current technique is easy to prepare, minimally invasive as an additional treatment with no risk of retrograde dissection.

   

  Jpn. J. Cardiovasc. Surg. 54: 37-41（2025）

  Keywords：preemptive TEVAR; distal anastomotic leak; zone 0 landing; surgeon-modified fenestrated and retrograde branched technique

  
  
• ［Peripheral Artery Disease］
• A Traumatic Brachial Artery Aneurysm Caused by Long-Term Inappropriate Use of Crutches　K. Higashi et al.　42
  A Traumatic Brachial Artery Aneurysm Caused by Long-Term Inappropriate Use of Crutches
  

  Kenta Higashi＊	Keiji Yunoki＊	Munehiro Saiki＊
  Yuto Narumiya＊	Shohei Morita＊	Teppei Toya＊
  Tomoya Inoue＊	Atsushi Tateishi＊	Kentaro Tamura＊
  Kunikazu Hisamochi＊

  
  

  （Department of Cardiovascular Surgery, Hiroshima Citizens Hospital of Hiroshima City Hospital Organizations＊, Hiroshima, Japan）
  

  The patient is a 66-year-old woman. She had been taking steroids for some years for rheumatoid arthritis and had been using crutches for some years because of multiple joint deformities. She presented herself to an orthopedic clinic for right upper extremity numbness and was diagnosed with cervical spondylosis and was kept under observation. However, 7 days later, a pulsatile mass on her right upper arm was found and she was referred to our hospital. Contrast-enhanced CT revealed a right brachial artery aneurysm （19×17×16 mm）, and the numbness was considered to be a symptom of nerve compression caused by the aneurysm. Since the cause of the brachial artery aneurysm was long-term inappropriate use of crutches, we confirmed that the patient would not use crutches and would use other assistive devices after the surgery, and then performed aneurysm resection and direct anastomosis under general anesthesia. Aneurysms of the upper extremities are rare and are often traumatic or iatrogenic pseudoaneurysms, and surgery is recommended because they can cause complications such as embolism, nerve compression, and rupture. In revascularization in cases where the aneurysm is caused by crutches, it is necessary to consider the risk of recurrence. In our case, we were able to perform direct anastomosis by switching the walking aid from crutches to Lofstrand clutches.

   

  Jpn. J. Cardiovasc. Surg. 54: 42-44（2025）

  Keywords：peripheral artery aneurysm; brachial artery aneurysm; crutch

  
  

U-40

• U-40 Column
• Recruitment of Young Cardiovascular Surgeons by the Cardiovascular Surgery Summer School　T. Tsujimoto et al.　U1
  Recruitment of Young Cardiovascular Surgeons by the Cardiovascular Surgery Summer School
  

  Takanori Tsujimoto＊

  
  

  (Department of Cardiovascular, The Jikei University Hospital＊, Tokyo, Japan)
  

  The Cardiovascular Surgery Summer School is a seminar for fourth- to sixth-year medical students, and first- to third-year residents to convey the attractiveness of cardiovascular surgery and recruit them, and is held for two days every August. The seminar was held at one location （Haneda Training Centre） with approximately 100 participants and 50 faculties this and last year. The author was in charge of planning and organising the events. The programme content and results of the participant questionnaires for both years are analysed and a programme for better recruitment of young cardiovascular surgeons is reported with some considerations.

   

  Jpn. J. Cardiovasc. Surg. 54(1): U1-U7 (2025).

  Keywords：Cardiovascular Surgery Summer School; U-40; Off the Job Training; recruitment

  
  

Editor’s Post Script

• M. Mutsuga