JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 54, No. 3, May 2025 CONTENTS

Preface

• The Cutting Edge Surgeon　T. Kunihara

Original

• The Impact of Optimal Fish-Mouth Fixation with an AORFIX AAA Endograft Combined with the AORFIX Technique: an Experimental Study　T. Azuma et al. 　95
  The Impact of Optimal Fish-Mouth Fixation with an AORFIX AAA Endograft Combined with the AORFIX Technique: an Experimental Study
  

  Takashi Azuma＊,＊＊	Masaaki Ikehara＊,＊＊	Masataka Hirota＊
  Satoru Domoto＊,＊＊	Hiroshi Niinami＊＊

  
  

  (Department of Cardiovascular Surgery, Adachi Medical Center＊, Tokyo, Japan, and Department of Cardiovascular Surgery, School of Medicine, Tokyo Women’s Medical University＊＊, Tokyo, Japan)
  

  Objective: The presence of a short, angulated neck in endovascular aneurysm repair remains challenging. The fish-mouth shape of the AORFIX AAA endograft enables trans-renal fixation, which can be advantageous in such cases. However, it is difficult to align the bottom line of the fish-mouth in a renal artery with an angulated neck. Here we devised a breakthrough technique to facilitate accurate fish-mouth positioning and achieved positive results. We then observed the ex vivo behavior of fish-mouth fixation of the AORFIX AAA endograft using this technique. Methods: A model of an abdominal aorta with a renal artery was created of porcine aortic vessels. Typical proximal touch-up ballooning was performed for reference. Kissing touch-up ballooning, which we named the Aligning Orifice of the Renal artery with fish-mouth FIXation （AORFIX） technique, between the aorta and the renal artery was performed as an interventional model. Results: In the reference model in which the endograft was deployed just below the renal artery, the bottom line of the fish-mouth was raised to cover the renal artery via touch-up ballooning. Unfortunately, its position did not improve with balloon angioplasty of the renal artery because the ring stents returned to the covered position after balloon deflation. In another reference model in which the endograft was deployed far enough below the renal artery, the bottom line of fish-mouth wasn’t raised beyond that. In the interventional model with the AORFIX technique, the bottom line of the fish-mouth was anchored at the lower end of the renal artery orifice. The ring stents were shaped to fit the orifice, and clearance of the renal artery was secured. Conclusion: This ex vivo observations of fish-mouth behavior support our surgical experiences. The AORFIX technique effectively affixed the fish-mouth to the renal artery orifice and created a longer-lasting effect. These results suggest that the AORFIX technique can be a good option in cases of challenging endovascular aneurysm repair with a short, angulated neck.

   

  Jpn. J. Cardiovasc. Surg. 54: 95-100（2025）

  Keywords：EVAR; short neck; angulated neck; AORFIX; kissing balloon inflation

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• A Case of Traumatic Left Atrial Appendage Injury Saved by Clamshell Thoracotomy　F. Yoshida et al.　101
  A Case of Traumatic Left Atrial Appendage Injury Saved by Clamshell Thoracotomy
  

  Fumiya Yoshida＊	Yasuhiro Kotani＊＊	Shingo Kasahara＊＊

  
  

  (Department of Emergency and Critical Care Medicine, Hyogo Emergency Medical Center＊, Kobe, Japan, and Department of Cardiovascular Surgery, Okayama University Graduate School of Medicine, Dentistry, Pharmaceutical Sciences and Okayama University Hospital＊＊, Okayama, Japan)
  

  Cardiac injuries caused by blunt chest trauma have a high mortality rate, and not only a median sternotomy but also a clamshell thoracotomy can be an alternative approach. In this report, we describe a case in hemostasis was achieved by clamshell thoracotomy in a left atrial appendage injury caused by blunt thoracic trauma. The patient is a 49-year-old woman. After an argument with her husband, she jumped off the balcony of her home on the 6th floor and fell in a supine position. She was brought to the hospital in shock, and pericardial effusion was found on FAST. She had cardiac arrest due to cardiac tamponade, and left anterolateral thoracotomy was performed to open the pericardium. After the removing the hematoma in the pericardial sac was removed, the patient experienced a return of spontaneous circulation, but a large amount of blood was seen spurting out, and the patient was transferred to a clamshell thoracotomy to secure the visual field. An injury of about 8 mm was observed in the left atrial appendage, which was sutured after establishing ECMO. The patient was discharged from the ICU on postoperative day 20 and discharged home unassisted on postoperative day 77. The cause of blunt cardiac injury is often traffic trauma, but this is a very rare case in which the patient suffered a left atrial appendage injury due to a fall trauma and clamshell thoracotomy was able to save her life. Therefore, clamshell thoracotomy is one of the options to open the chest in certain clinical situation.

   

  Jpn. J. Cardiovasc. Surg. 54: 101-104（2025）

  Keywords：blunt chest trauma; left atrial appendage injury; Clamshell thoracotomy; ECMO

  
  
• Mitral Valve Replacement under Ventricular Fibrillation via Right Thoracotomy in an Elderly Patient with Mitral Stenosis Caused by MitraClip with History of Coronary Artery Bypass Surgery and Severe Aortic Calcification　Y. Tamai et al.　105
  Mitral Valve Replacement under Ventricular Fibrillation via Right Thoracotomy in an Elderly Patient with Mitral Stenosis Caused by MitraClip with History of Coronary Artery Bypass Surgery and Severe Aortic Calcification
  　　　 　　　

  Yumeka Tamai＊	Chikara Ueki＊＊	Tatsuya Ogawa＊
  Ryusuke Hamada＊	Shinsuke Kotani＊	Yuji Sekine＊
  Takahiro Ishigaki＊	Satoshi Asada＊	Kazuma Okamoto＊
  Gennichi Sakaguchi＊

  
  

  (Department of Cardiovascular Surgery, Kindai University Faculty of Medicine＊, Osaka Sayama, Japan, and Shizuoka Graduate University of Public Health＊＊, Shizuoka, Japan)
  

  We report a case of mitral valve replacement without aortic cross clamp in a patient with MitraClip failure. The patient is an 83-year-old man with a history of coronary artery bypass surgery 31 years earlier. He developed heart failure due to severe mitral regurgitation. He underwent MitraClip, but it caused mitral stenosis and hemodynamic instability. Considering the severe calcification of the ascending aorta and previous bypass grafts, typical median sternotomy surgery with cross clamp had to be avoided. We performed mitral valve replacement via right thoracotomy under ventricular fibrillation. The postoperative course was favorable. Mitral valve surgery with ventricular fibrillation could be undertaken safely for a patient with difficulty in aortic cross clamp.

   

  Jpn. J. Cardiovasc. Surg. 54: 105-108（2025）

  Keywords：porcelain aorta; unclampable aorta; mitral valve replacement under ventricular fibrillation; right thoracotomy

  
  
• A Case of Successful Anticoagulant Therapy for Acute Thrombosis Following Mitral Valve Replacement under V-A ECMO　A. Yamada et al.　109
  A Case of Successful Anticoagulant Therapy for Acute Thrombosis Following Mitral Valve Replacement under V-A ECMO
  　　　 　　　

  Akitoshi Yamada＊	Ryo Tohma＊	Masanobu Sato＊
  Yoshihisa Morimoto＊	Kunio Gan＊	Tatsuro Asada

  
  

  (Department of Cardiovascular Surgery, Kitaharima Medical Center＊, Ono, Japan)
  

  A 76-year-old woman, with a history of secundum atrial septal defect （ASD） patch closure 11 years earlier, presented with loss of appetite and dyspnea. She was treated for heart failure due to aortic regurgitation （AR）, mitral regurgitation （MR）, tricuspid regurgitation （TR）, and atrial fibrillation （Af）. Upon transfer to our department, she went into shock, leading to the introduction of V-A ECMO and IABP. Emergency surgeries, including aortic valve replacement （AVR）, mitral valve replacement （MVR）, tricuspid valve annuloplasty （TAP）, and left atrial appendage closure, were performed. A second surgery for hemostasis was necessary, and V-A ECMO was removed on the second postoperative day. Transesophageal echocardiography revealed mitral bioprosthetic valve thrombosis. The patient was treated with heparin and warfarin, resulting in improved pressure gradients and removal of IABP by the seventh day. The sternum was closed on the seventeenth day, and she was transferred to the general ward on the thirty-ninth day. This case demonstrates the effective use of anticoagulant therapy for early valve thrombosis after mitral valve replacement under V-A ECMO.

   

  Jpn. J. Cardiovasc. Surg. 54: 109-113（2025）

  Keywords：mitral valve replacement; V-A ECMO; acute thrombosis of a bioprosthetic valve; anticoagulant therapy

  
  
• A Case of Surgical AVR with Rapid Deployment Aortic Valve for Paravalvular Leak after TAVR　M. Hatakeyama et al. 　114
  A Case of Surgical AVR with Rapid Deployment Aortic Valve for Paravalvular Leak after TAVR
  　　　 　　　

  Masaharu Hatakeyama＊	Koichi Nagaya＊	Masayuki Otani＊
  Ko Sakatsume＊	Nobuaki Suzuki＊	Ichiro Yoshioka＊
  Shinya Masuda＊

  
  

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

  An 84-year-old man underwent transcatheter aortic valve replacement （TAVR） for severe aortic stenosis with heart failure. Paravalvular leak （PVL） of the aortic valve was observed immediately after the operation, and the heart failure was difficult to manage; closure with a vascular plug was attempted, but PVL did not improve. Therefore, four months after TAVR, the decision was made to perform surgical aortic valve replacement （SAVR）. The operation was expected to take a long time due to the concomitant mitral valve replacement, ascending aortic valve replacement and pulmonary vein isolation, in addition to SAVR with removal of the TAVR valve, so a rapid deployment valve was used for aortic valve replacement. The patient’s postoperative course was good, with no complications. Postoperative echocardiography showed no problems with the replaced aortic or mitral valves. Twenty-six days after surgery, the patient was discharged home, although it took time for rehabilitation due to the long hospital stay after TAVR. More than two years have passed since the surgery, and the patient is currently an outpatient with no symptoms of heart failure. The present report describes the use of a rapid deployment valve for surgical AVR after TAVR with good results.

   

  Jpn. J. Cardiovasc. Surg. 54: 114-117（2025）

  Keywords：TAVR; rapid deployment valve; AVR; paravalvular leak

  
  
• A Case of Repair of a Ventricular Septal Perforation via Right Ventricular Approach with Left Anterior Descending Coronary Artery Preservation　R. Tateishi et al.　118
  A Case of Repair of a Ventricular Septal Perforation via Right Ventricular Approach with Left Anterior Descending Coronary Artery Preservation
  　　　 　　　

  Retsu Tateishi＊	Yoshinori Nakahara＊＊	Kokoro Tabata＊
  Kazuki Morooka＊	Motoharu Shimozawa＊	Fumiya Haba＊
  Kosaku Nishigawa＊	Syunya Ono＊	Takeyuki Kanemura＊

  
  

  （Department of Cardiovascular Surgery, IMS Katsushika Heart Center＊, Tokyo, Japan, and Department of Cardiovascular Surgery, Sakakibara Heart Institute＊＊, Tokyo, Japan）
  

  The patient was a 73-year-old female who developed a ventricular septal perforation （VSP） following an acute anterior myocardial infarction, requiring emergency surgery. We made an incision in the right ventricle （RV） wall, 2 centimeters away from, and parallel to, the left anterior descending coronary artery （LAD）. We found an aproximately 15 mm perforation. The VSP was closed by the extended sandwich patch technique, taking care not to the injure LAD. Furthermore, coronary artery bypass graft （CABG） left internal thoracic artery （LITA） to LAD was performed. The postoperative course was good, and no residual shunt was detected on the echocardiogram on the fifth day after surgery. Postoperative coronary artery computed tomography （CT） showed all grafts, including the LITA-LAD, were patent, and the patient was discharged on the twelfth day after surgery. There is controversial about whether or not to perform revascularization of the culprit artery during VSP repair. Based on this case, it was thought that complete revascularization, including the culprit artery, should be considered in cases of VSP.

   

  Jpn. J. Cardiovasc. Surg. 54: 118-121（2025）

  Keywords：ventricular septal perforation; complete revascularization

  
  
• ［Aortic Disease］
• A Successful Case of Graft Infection after Total Debranched TEVAR for Distal Arch Aneurysm Treated by Graft Removal, Replacement of Total Arch and Descending Aorta, and Omental Flap Installation　A. Tanaka et al.　122
  A Successful Case of Graft Infection after Total Debranched TEVAR for Distal Arch Aneurysm Treated by Graft Removal, Replacement of Total Arch and Descending Aorta, and Omental Flap Installation
  　　　 　　　

  Aya Tanaka＊	Hiroyuki Hayashi＊	Kotaro Tsunemi＊
  Takanori Oka＊	Yutaka Okita＊

  
  

  （Takatsuki General Hospital Cardiovascular Center＊, Takatsuki, Japan）
  

  We present the case of a 56-year-old man who had undergone a total debranched TEVAR for a distal arch aneurysm in an other hospital 7 years eariler. One year after the surgery, a graft infection occurred and the left subclavian artery graft was removed and an axillo-axillary bypass was done. However, the infection persisted and two cutaneous fistulae at the left neck and median sternotomy were recognized. Preoperative FDG-PET CT revealed a high uptake of FDG in the left common carotid artery graft, the stent graft in the ascending aorta, and the left neck wound and median sternotomy site. After we exposed the left common carotid artery, the left chest was entered through a posterolateral thoracotomy. The cardiopulmonary bypass was initiated by cannulating the left common femoral vessels and main pulmonary artery, and core cooling was done to 23℃．The descending aorta was clamped at the Th10 level, and the proximal descending aorta to arch was opened to remove the infected stent graft. Selective antegrade cerebral perfusion was started and antegrade cardioplegia was given. The ascending-arch-descending aorta was replaced with a rifampicin-soaked Dacron graft, followed by left common carotid artery reconstruction using an 8 mm Gore-Tex graft. The new graft was wrapped with a pedicled omental flap. Postoperative antibiotic therapy was continued for 6 weeks and the fistulae were surgically closed. The patient was discharged and is back to the normal life.

   

  Jpn. J. Cardiovasc. Surg. 54: 122-126（2025）

  Keywords：post TEVAR; graft infection; revascularization; cutaneous fistula; omental flap

  
  
• Endovascular Treatment for Pseudoaneurysm at the Distal Anastomosis after the Surgical Repair of Aortic Coarctation　N. Tateishi et al.　127
  Endovascular Treatment for Pseudoaneurysm at the Distal Anastomosis after the Surgical Repair of Aortic Coarctation
  　　　 　　　

  Naoki Tateishi＊	Ryo Imada＊	Fumiya Ono＊
  Yushi Yamashita＊	Koji Tao＊	Tamahiro Kinjo＊

  
  

  (Cardiovascular Surgery, Kagoshima Medical Center＊, Kagoshima, Japan)
  

  A 70-year-old woman with a history of bypass surgery for coarctation of the aorta （CoA） at approximately 10 years of age was referred to our hospital after a descending thoracic aortic aneurysm was discovered during a preoperative examination for uterine cancer. Contrast-enhanced CT revealed a 62×47 mm aneurysm in the descending thoracic aorta, connected to the bypass vessel, leading to the diagnosis of an anastomotic pseudoaneurysm following CoA surgery. Due to the large diameter of the aortic aneurysm and the high risk of rupture, we performed a left axillary artery to left femoral artery bypass in addition to thoracic endovascular aortic repair （TEVAR）. Postoperative CT indicated no endoleak, and the patient was discharged after uterine cancer surgery with an uneventful recovery.

   

  Jpn. J. Cardiovasc. Surg. 54: 127-129（2025）

  Keywords：coarctation of aorta; pseudoaneurysm; TEVAR

  
  
• A Case of Antegrade Thoracic Endovascular Aneurysm Repair Accessed from an Ascending Aorto-Bi-Iliac Bypass Graft　K. Kato et al.　130
  A Case of Antegrade Thoracic Endovascular Aneurysm Repair Accessed from an Ascending Aorto-Bi-Iliac Bypass Graft
  　　　 　　　

  Kenichi Kato＊	Yoshihiko Kurimoto＊	Takahiko Masuda＊
  Ryushi Maruyama＊	Mika Yamamoto＊	Keita Sasaki＊
  Naritomo Nishioka＊	Shuichi Naraoka＊

  
  

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

  In thoracic endovascular aneurysm repair （TEVAR）, the common femoral artery is typically used as the standard vascular access. However, in some cases, alternative vascular accesses must be considered, or endovascular treatment may need to be abandoned due to vascular diameter or characteristics. A female in her 70 s presented with saccular aortic aneurysms located at the distal arch and descending aorta, possibly secondary to bacteremia. She had a history of partial arch replacement and ascending aorto-bi-iliac artery bypass for ascending aortic aneurysm, as well as calcified abdominal aortic stenosis, performed five years prior. In this case, we successfully treated the aneurysms with antegrade TEVAR, accessing through the extra-anatomical bypass graft, which was exposed in the epigastric preperitoneal space. This is the first case report of TEVAR using access from an extra-anatomical bypass graft connecting the ascending aorta to the lower extremity.

   

  Jpn. J. Cardiovasc. Surg. 54: 130-134（2025）

  Keywords：endovascular treatment access; extra-anatomical bypass graft; thoracic aortic aneurysm; thoracic endovascular aneurysm repair （TEVAR）

  
  
• ［Peripheral Artery Disease］
• A Surgical Case of Vascular Type Ehlers-Danlos Syndrome with Rupture of the Brachial rtery　T. Fujimoto et al.　135
  A Surgical Case of Vascular Type Ehlers-Danlos Syndrome with Rupture of the Brachial Artery
  　　　 　　　

  Takahiro Fujimoto＊	Kentaro Honda＊	Hideki Kunimoto＊
  Mizuho Ikuchi＊	Yuya Ideguchi＊	Kota Agematsu＊
  Yoshiharu Nishimura＊

  
  

  （Department of Vascular Surgery, Saiseikai Wakayama Hospital＊, Wakayama, Japan）
  

  A 29-year-old man was diagnosed with vascular type Ehlers-Danlos syndrome after right hepatic artery aneurysm rupture. He was admitted to a hospital with hematoma and sudden pain of right upper limb. After imaging diagnosis by echography and contrast-enhanced CT, We performed emergency surgery. Intraoperative findings revealed brachial artery rupture, so we performed arterial replacement by using a great saphenous vein graft. The postoperative course was uneventful. We report a rescued case of brachial artery rupture with vascular type Ehlers-Danlos syndrome by bypass using great saphenous vein graft.

   

  Jpn. J. Cardiovasc. Surg. 54: 135-137（2025）

  Keywords：Ehlers-Danlos syndrome; brachial artery rupture; saphenous vein graft

  
  

Progress in Cardiovascular Surgery (2024)

• Progress in Coronary Artery Surgery in 2024　R. Ushioda and H. Kamiya　138
• Recent Advances in Valvular Heart Disease and Arrhythima in 2024　Y. Tokuda　141

U-40 Column

• Task Sharing between Cardiovascular Surgeons and Nurse Practitioners in Japan: Current Status and Issues　Y. Kameda et al. 　U1
  Task Sharing between Cardiovascular Surgeons and Nurse Practitioners in Japan: Current Status and Issues
  　　　 　　　

  Yuika Kameda＊	Takahiro Ito	Taisuke Shibuya
  Takao Miki	Suguru Miyazaki	Rihito Tamaki
  Hironobu Nishiori	Kaori Mori	Misato Tokioka
  Kazuki Tamura

  
  

  (Department of Cardiovascular Surgery, Saiseikai Utsunomiya Hospital1), Utsunomiya, Japan)
  

  With the full implementation of physician workstyle reform in 2024, task sharing in cardiovascular surgery has become increasingly important. This study conducted a nationwide questionnaire survey targeting young cardiovascular surgeons and nurses certified for specified medical acts to investigate the current status and challenges of task sharing in this field. Results revealed that while nurses were actively involved in postoperative care and certain bedside procedures, their participation in intraoperative and emergency tasks remained limited. From the nurses’ perspective, concerns were raised regarding career development, compensation, and the lack of structured educational support. These findings suggest that, to ensure sustainable and effective task sharing in cardiovascular surgery, it is essential to establish clear role definitions and implement systemic organizational support for certified nurses.

   

  Jpn. J. Cardiovasc. Surg. 54(3): U1-U7 (2025).

Editor’s Post Script　

• T. Horii