JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 54, No. 4, July 2025 CONTENTS

Preface

• Go Abroad, Grow Beyond T. Kudo

Original

• Evaluation of the Administration of Fibrinogen Concentrates for Performing Hemostatic Therapy during Thoracic Aortic Surgery　A. Usui et al.　143
  Evaluation of the Administration of Fibrinogen Concentrates for Performing Hemostatic Therapy during Thoracic Aortic Surgery
  

  Akihiko Usui1, 2）	Kenji Minatoya3）	Kenji Okada4）
  Hiroaki Osada3）	Katsuhiro Yamanaka4）	Hideki Ito1）
  Shigeyuki Matsui5）	Takahiro Tamura6）	Masato Mutsuga1）

  
  

  (Department of Cardiac Surgery, Nagoya University Graduate School of Medicine1), Nagoya, Japan, Cardiovascular Surgery, Fujita Health University Okazaki Medical Center2), Okazaki, Japan, Department of Cardiovascular Surgery, Kyoto University Graduate School of Medicine3), Kyoto, Japan, Department of Cardiovascular Surgery, Kobe University Graduate School of Medicine4), Kobe, Japan, Department of Biostatics5), and Department of Anesthesiology6), Nagoya University Graduate School of Medicine, Nagoya, Japan)
  

  Purpose: We observed whether the coagulation function improved and the bleeding tendency was controlled by fibrinogen concentrates or not. We thus evaluated their usefulness in treating patients with hypofibrinogenemia during thoracic aortic surgery. Methods: In 32 patients with hypofibrinogenemia under 150 mg/dl during either thoracic or thoracoabdominal aortic surgery, the blood coagulation ability was observed by ROTEM sigma and the 3-minute bleeding amount was measured during surgery. Results: The blood fibrinogen levels decreased to 109±26 mg/dl at the end of cardiopulmonary bypass, but they significantly increased to an average of 231±38 mg/dl after fibrinogen concentrates administration （p＜0.0001）. The average 3-minute bleeding amount was 144±88 ml after heparin neutralization, but it significantly decreased to 85±74 ml after fibrinogen concentrates administration （p=0.0001）. However, the 3-minute bleeding amount actually increased in 6 cases, while 26 cases （82%） showed a decrease in the bleeding amount. Fibtem A10 was extremely low at 4.8±2.7 mm after heparin neutralization, but the value increased to 14.1±4.1 mm after fibrinogen concentrates administration, thereby exceeding the value observed at the start of surgery （p＜0.0001). Extem A10, which reflects the extrinsic coagulation ability, and INTEM A10, which reflects the intrinsic coagulation ability, were both low at 31.3±11.0 mm and 30.9±10.7 mm, respectively, after heparin neutralization, but they significantly increased to 42.2±8.9 mm and 39.1±8.7 mm （p＜0.0001）, respectively, after fibrinogen concentrates administration. There were no operative deaths among the 32 cases, but there were three cases in which thromboembolism could not be ruled out. Two of them had myocardial infarction, which had been caused by the occlusion of the reconstructed right coronary artery, while the other case suffered from a new cerebral infarction after undergoing aortic arch replacement, but the relationship between these events and fibrinogen concentrates administration could not be clarified. Conclusion: The administration of fibrinogen concentrates rapidly increased the blood fibrinogen levels and reduced bleeding. In addition, significant improvements in the extrinsic and intrinsic coagulation abilities were observed after fibrinogen concentrates administration.

   

  Jpn. J. Cardiovasc. Surg. 54: 143-153（2025）

  Keywords：hypofibrinogenemia; fibrinogen concentrates; thoracic aortic surgery; bleeding tendency; thrombo-elastometry

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• Aortic Valve Replacement with Aortic Annulus Enlargement Using the L-Incision Procedure for Aortic Stenosis with Calcification of the Narrow Aortic Annulus　G. Fukushima et al.　154
  Aortic Valve Replacement with Aortic Annulus Enlargement Using the L-Incision Procedure for Aortic Stenosis with Calcification of the Narrow Aortic Annulus
  

  Go Fukushima＊	Shingo Hirao＊	Go Yamashita＊
  Atsushi Sugaya＊	Tatsuhiko Komiya＊

  
  

  （Department of Cardiovascular Surgery, Kurashiki Central Hospital＊, Kurashiki, Japan）
  

  Aortic annulus enlargement is a procedure often performed to prevent prosthesis-patient mismatch. This report describes the procedure that allowed us to achieve adequate annulus enlargement in a case enlargement with the conventional Nicks procedure was difficult. The patient was a 70-year-old woman who underwent aortic valve replacement along with aortic annulus enlargement, for severe aortic valve stenosis. The conventional Nicks procedure was not performed due to calcification of the non-coronary sinus of Valsalva and the aortic valve commissure between the left coronary cusp and the non-coronary cusp. We decided to incise the non-coronary sinus of Valsalva from 2 mm lateral to the left coronary-non-coronary commissure. Although the cut line was extended across the aortic annulus into the aorto-mitral curtain, the aortic annulus and anterior mitral leaflet were not far enough apart for adequate enlargement. We therefore decided to add a horizontal incision line toward the right fibrous trigone and create an L-shaped incision line. As a result, the aortic annulus was dilated 10 mm and a 21 mm Inspiris prosthesis （Edwards Lifesciences, Irvine, CA, USA） was successfully implanted in the supra-annular position. The postoperative course was uneventful and the patient was discharged on postoperative day 16 in an ambulatory condition. The postoperative echocardiogram showed no prosthesis-patient mismatch or perivalvular leakage.An L-incision may be one of the options to enlarge the aortic annulus in cases where the conventional Nicks procedure is difficult to perform.

   

  Jpn. J. Cardiovasc. Surg. 54: 154-158（2025）

  Keywords：aortic valve replacement; prosthesis-patient mismatch; aortic annulus enlargement

  
  
• A Case of Aortic Valve Replacement in a Patient with Alkaptonuria　T. Yazawa et al. 　159
  A Case of Aortic Valve Replacement in a Patient with Alkaptonuria
  

  Tsubasa Yazawa＊	Akio Koyama＊＊	Wataru Uchida＊

  
  

  (Department of Cardiac Surgery＊, and Department of Vascular Surgery＊＊, Toyota Memorial Hospital, Toyota, Japan)
  

  Alkaptonuria （AKU） is a rare genetic disorder with an estimated incidence of 1 in 100,000 to 1 in 250,000 individuals. It is characterized by a triad of homogentisic aciduria, arthritis, and ochronosis （black pigmentation of connective tissues）. We report a case of a 72-year-old male patient previously diagnosed with AKU, who presented with severe aortic valve stenosis and underwent surgical aortic valve replacement. Intraoperative findings revealed black discoloration of the aorta and black calcification of the aortic valve, which are characteristic of AKU. A mechanical On-X valve （On-X Life Technologies, Austin, TX, USA） was implanted. The patient remains free of complications at 1 year and 2 months postoperatively. The black calcification of the aortic valve is a hallmark finding in AKU and can serve as a diagnostic clue during cardiac surgery. Patients with AKU are prone to accelerated calcification, and reports indicate a risk of structural valve deterioration （SVD） following bioprosthetic valve implantation. As such, mechanical valves might be selected in these patients to mitigate this risk. This case highlights the importance of recognizing the distinctive intraoperative features of AKU and considering mechanical valve implantation to reduce the likelihood of SVD. A literature review is provided to discuss further these findings and their implications in managing AKU-related cardiac conditions.

   

  Jpn. J. Cardiovasc. Surg. 54: 159-162（2025）

  Keywords：Alkaptonuria; aortic valve replacement; aortic stenosis

  
  
• A Case of Left Ventricular Pseudo-False Aneurysm Occurred in the Apex　M. Arimoto et al.　163
  A Case of Left Ventricular Pseudo-False Aneurysm Occurred in the Apex
  

  Munehito Arimoto＊	Yosuke Kitanaka＊	Masashi Tanaka＊＊

  
  

  （Department of Cardiac Surgery, Kawaguchi Municipal Medical Center＊, Kawaguchi, Japan, and Department of Cardiovascular Surgery, Nihon University School of Medicine＊＊, Tokyo, Japan）
  

  We report a case of a patent with a left ventricular pseudo-false aneurysm occurring in the apex. A 77-year-old man, he visited our hospital because of an abnormal electrocardiogram. Coronary computed tomography revealed stenosis of the left anterior descending artery and a small aneurysm in the apex. A left ventriculogram after percutaneous coronary intervention showed the aneurysm similarly. We decided to remove it to prevent rupture. We performed an operation, an aneurysmectomy. His clinical course was uneventful. Pathological examination after the operation showed that the aneurysm wall contained residual myocardium. This finding showed a left ventricular pseudo-false aneurysm.

   

  Jpn. J. Cardiovasc. Surg. 54: 163-167（2025）

  Keywords：left ventricular pseudoaneurysm; old myocardial infarction

  
  
• A Case of IgG4-Related Coronary Periarteritis Diagnosed with Refractory Hemorrhagic Pericardial Effusion　S. Sugimoto et al.　168
  A Case of IgG4-Related Coronary Periarteritis Diagnosed with Refractory Hemorrhagic Pericardial Effusion
  

  Satoshi Sugimoto＊	Tomoyoshi Yamashita＊	Hidetoshi Yamauchi＊

  
  

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

  IgG4-related disease is a systemic fibroinflammatory disorder characterized by IgG4-positive plasma cell infiltration, with coronary artery involvement being rare. We report a case of IgG4-related coronary periarteritis diagnosed following refractory hemorrhagic pericardial effusion. The patient was a 79-year-old man who had suffered a myocardial infarction one year earlier and had undergone percutaneous coronary intervention. He subsequently developed hemorrhagic pericardial effusion and heart failure, which temporarily improved with pericardiocentesis and medical therapy but repeatedly recurred. A comprehensive evaluation for the underlying cause of the hemorrhagic pericardial effusion ruled out malignancy and collagen disease; however, imaging revealed a peri-coronary mass. Consequently, he was referred to our department for biopsy and pericardial drainage. A median sternotomy was performed, revealing a mass surrounding the right coronary artery. A partial resection of the lesion was submitted for pathological examination, and a pericardial-peritoneal window procedure was performed. Histopathological analysis demonstrated infiltration of IgG4-positive plasma cells, leading to a diagnosis of IgG4-related coronary periarteritis. Postoperatively, without corticosteroid therapy, the patient experienced no recurrence of pericardial effusion, heart failure, or angina. He remained in good condition for 11 years following surgery until his death from lung cancer. It is important to consider IgG4-related coronary periarteritis, in addition to malignancies and collagen diseases, in the differential diagnosis of coronary periarterial masses associated with refractory hemorrhagic pericardial effusion.

   

  Jpn. J. Cardiovasc. Surg. 54: 168-173（2025）

  Keywords：IgG4-related disease; coronary periarteritis; refractory hemorrhagic pericardial effusion; pericardial-peritoneal window

  
  
• ［Aortic Disease］
• Acute Aortic Occlusion of Abdominal Aortic Aneurysm and Bilateral Common Iliac Artery Aneurysm　K. Hachiro et al. 　174
  Acute Aortic Occlusion of Abdominal Aortic Aneurysm and Bilateral Common Iliac Artery Aneurysm
  

  Kohei Hachiro＊, ＊＊	Kazuhiko Katsuyama＊	Tomoyuki Yamada＊
  Tomoaki Suzuki＊＊

  
  

  （Division of Cardiovascular Surgery, Shiga General Hospital＊, Moriyama, Japan, and Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science＊＊, Otsu, Japan）
  

  A 63-year-old man presented to our hospital with sudden pain in both lower extremities. Computed tomography showed abdominal aortic aneurysm and bilateral common iliac artery aneurysms filled with thrombosis and occlusion of the right popliteal artery. We performed an emergency operation. A midline abdominal incision was made to expose the abdominal aortic aneurysm and bilateral common iliac artery aneurysm. Using a 16×8 mm bifurcated prosthesis （Hemashield Platinum）, the proximal end of the graft was anastomosed to the abdominal aorta below the bilateral renal arteries. The right common femoral artery was incised longitudinally to remove the thrombosis from the right popliteal artery, after which the right leg of the graft was guided to the right groin, and an end-to-side anastomosis was performed at the incision site. As the right side, the left leg of the graft was guided to the left groin, and an end-to-side anastomosis was performed at the left common femoral artery. Bilateral common iliac artery was occluded just above the bifurcation of the external and internal iliac arteries. Postoperative enhanced computed tomography showed patent extremity arteries and muscle necrosis in the right lower leg．Right foot drop occurred after surgery, but the condition improved over time．The patient was discharged 32 days after surgery.

   

  Jpn. J. Cardiovasc. Surg. 54: 174-177（2025）

  Keywords：acute aortic occlusion; abdominal aortic aneurysm; bilateral common iliac artery aneurysm

  
  
• Successful Management of Intraoperative Cardiac Arrest due to Access Route Injury during TEVAR in a Patient with Ischemic Heart Disease　Y. Nishida et al.　178
  Successful Management of Intraoperative Cardiac Arrest due to Access Route Injury during TEVAR in a Patient with Ischemic Heart Disease
  

  Yuji Nishida＊	Naoki Kitazawa＊＊	Naoki Saito＊

  
  

  （Department of Thoracic Surgery, Kouseiren Takaoka Hospital＊, Takaoka, Japan, and Department of Cardiovascular Surgery, Kanazawa University Hospital＊＊, Kanazawa, Japan）
  

  Background: Thoracic endovascular aortic repair （TEVAR） has become a widely accepted minimally invasive treatment for thoracic aortic aneurysms. However, it is associated with potentially fatal complications, such as access route injury and retrograde type A aortic dissection （RTAD）. Case presentation: An 86-year-old woman with a history of hypertension, dyslipidemia, lumbar spinal stenosis, and frailty （Clinical Frailty Scale score of 5） presented with hoarseness. Contrast-enhanced computed tomography （CT） revealed a saccular thoracic aortic aneurysm （55 mm） in the distal aortic arch. Preoperative coronary angiography identified significant stenosis of the left anterior descending artery （LAD）. TEVAR with left subclavian artery debranching was planned, followed by staged percutaneous coronary intervention （PCI）. The TEVAR procedure, using a GORE® TAG® stent graft and embolization of the left subclavian artery, was successfully performed. However, during closure, the patient experienced sudden cardiac arrest due to pulseless electrical activity （PEA）. Immediate cardiopulmonary resuscitation （CPR） and diagnostic maneuvers were initiated. Median sternotomy and direct cardiac massage were performed, followed by central venoarterial extracorporeal membrane oxygenation （VA-ECMO） to stabilize hemodynamics. Subsequent angiography revealed massive retroperitoneal bleeding caused by right external iliac artery injury. A short-segment graft replacement for the iliac artery was performed. Persistent left ventricular dysfunction despite ECMO support prompted emergency coronary artery bypass grafting （CABG） for LAD stenosis. The patient showed significant improvement in cardiac function, enabling ECMO weaning. Outcome: The patient had no neurological deficits and was discharged for rehabilitation on postoperative day 35. She returned to independent daily activities within two months. Conclusion: This case demonstrates the critical role of timely diagnosis and multidisciplinary intervention in managing access route injuries during TEVAR, particularly in high-risk patients with ischemic heart disease and advanced age.

   

  Jpn. J. Cardiovasc. Surg. 54: 178-183（2025）

  Keywords：thoracic aortic aneurysm; TEVAR; access route injury; cardiac arrest; ischemic heart disease

  
  
• A Case of Aorto-Esophageal Fistula Following Thoracic Endovascular Aortic Repair Revealed in Autopsy after Sudden Death due to Type A Acute Aortic Dissection　Y. Nakamura and H. Takagi　184
  A Case of Aorto-Esophageal Fistula Following Thoracic Endovascular Aortic Repair Revealed in Autopsy after Sudden Death due to Type A Acute Aortic Dissection
  

  Yuhi Nakamura＊	Hisato Takagi＊

  
  

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

  A 69-year-old man underwent thoracic endovascular aortic repair (TEVAR) for type B subacute aortic dissection (AD) to prevent its false-lumen expanding. The patient complained of a fever and malaise 19 months after the TEVAR. Ga-67 scintigraphy showed accumulation of radioactivity at the thoracic aortic stent graft (TA-SG). Infection of the TA-SG was diagnosed, and antibiotic therapy was initiated. Although the patient’s condition was improved temporarity, he was readmitted three times for exacerbation of the infection. The patient presented with back pain 31 months after the TEVAR. Computed tomography showed migration of the distal end of the TA-SG, and additional TEVAR was performed. A month after the additional TEVAR, the patient was admitted with toothache and headache after tooth extraction on the same day. Despite a lack of chest symptoms, the patient suddenly fell into cardiopulmonary arrest in the next day and died. In autopsy, there were two aorta-esophageal fistulae (AEF), pus discharge between the TA-SG and the aortic wall, and aortic root rupture. Rupture of type A acute AD with an entry away from the proximal end of the TA-SG (i.e., independent of the TA-SG) was diagnosed. Even though persistent bacteremia is latent, it may cause fistulae or dissections in the aortic wall through mechanisms such as inflammatory-cytokine expression or vasa-vasorum embolism. In the present patient, it is considered that TA-SG infection-induced bacteremia was relevant to AEF and leading to the type A acute AD. Although it is often difficult to be diagnosed without typical symptoms such as hematemesis, AEF and other aortic diseases caused by aortic fragility should be kept in mind in case of persistent bacteremia after TEVAR.

   

  Jpn. J. Cardiovasc. Surg. 54: 184-190 (2025)

  Keywords：aorto-esophageal fistula; thoracic endovascular aortic repair; stent graft infection; autopsy; type A acute aortic dissection

  
  
• ［Peripheral Artery Disease］
• A Case of Internal Mammary Artery Aneurysm Treated by Coil Embolization with Direct Approach for the Internal Mammary Artery Using the Chamberlain Method　 H. Ueda et al.　191
  A Case of Internal Mammary Artery Aneurysm Treated by Coil Embolization with Direct Approach for the Internal Mammary Artery Using the Chamberlain Method
  

  Hideyasu Ueda＊	Kenji Iino＊	Ai Sakai＊
  Masaki Kitazawa＊	Hiroki Nakabori＊	Yoshitaka Yamamoto＊
  Akira Murata＊	Hirofumi Takemura＊

  
  

  (Cardiovascular Surgery, Kanazawa University＊, Kanazawa, Japan)
  

  An 81-year-old female underwent a medical examination, including thoracic computed tomography (CT). CT revealed a left internal mammary artery aneurysm (measuring 33 mm in diameter). She was referred to our department for further treatment. An initial attempt at coil embolization was made, but the guidewire became trapped within the mural thrombus of the aneurysm, preventing access to the outflow vessel. Consequently, the catheterization was abandoned. We then decided to perform a direct approach for IMA with the Chamberlain method, enabling successful coil embolization of the aneurysm’s outflow vessel through a retrograde approach. The postoperative course was uneventful. Postoperative CT showed complete thrombosis and a reduction in aneurysm size. We propose that the Chamberlain method for direct access to the internal mammary artery is an effective and minimally invasive treatment option for elderly patients or those with limited operative tolerance in cases of internal mammary artery aneurysm, as it avoids the need for sternotomy or thoracotomy.

   

  Jpn. J. Cardiovasc. Surg. 54: 191-194 (2025)

  Keywords：Internal mammary artery aneurysm; coil embolization; Chamberlain method

  
  

Progress in Cardiovascular Surgery (2024)

• Guidelines of 2024 Myocardium Protection in Japan　─Current Trend toward the World─　K. Morita 　195
• Advances in Aortic Surgery in 2024　K. Yamanaka　202

U-40

• U-40 Column
• Facing Acute Aortic Dissection: Are You a Fully-Fledged Surgeon Once You Have Managed a Dissection ?　Y. Kinugasa et al.　U1
  Facing Acute Aortic Dissection: Are You a Fully-Fledged Surgeon Once You Have Managed a Dissection ?
  

  Yusuke Kinugasa＊	Soichiro Hirose	Yuichiro Hamada
  Yutaro Matsuno	Chiaki Ikeda	Seimei Go
  Takumi Ueno	Hiromu Horie	Yuki Yoshikawa
  Yoshihiko Kuinose	Hiroshi Sakamoto	Tomohide Higaki
  Yoshinori Inoue

  
  

  (Department of Cardiovascular Surgery, Chikamori Hospital＊, Kochi, Japan)
  

  For young cardiovascular surgeons, performing surgery for acute aortic dissection is a milestone they aspire to achieve. To attain the role of the primary surgeon, they strive to master surgical techniques specific to their institution, dedicating themselves to rigorous training. However, there remains significant variability in surgical approaches to aortic dissection across institutions, with many aspects lacking standardization. In this context, we conducted a nationwide survey aimed at helping young cardiovascular surgeons understand the position of their institution’s practices and their own perspectives in relation to national standards. The survey also sought to capture their everyday questions and concerns regarding aortic dissection surgery. This report presents the findings of that survey, with the aim of contributing to the future development of aortic dissection management.

   

  Jpn. J. Cardiovasc. Surg. 54(4): U1-U6 (2025).

  
  

Editor’s Post Script

• K. Hoshina