JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 54, No. 5, September 2025 CONTENTS

Preface

• From the Dawning Era to the Future H. Goto

Case Reports

• ［Congenital Heart Disease］
• An Adult Case of Double Chambered Right Ventricle after Interruption of Regular Follow-up for Ventricular Septal Defect　T. Miyazaki・T. Shinkawa　207
  An Adult Case of Double Chambered Right Ventricle after Interruption of Regular Follow-up for Ventricular Septal Defect
  

  Takako Miyazaki＊	Takeshi Shinkawa＊＊

  
  

  （Department of Cardiovascular Surgery, Otsu City Hospital＊, Kyoto, Japan, and Department of Cardiovascular Surgery, Tokyo Women’s Medical University Hospital＊＊, Tokyo, Japan）
  

  We report an adult case of double chambered right ventricle （DCRV）, in which right ventricular outflow tract stenosis is thought to have progressed after interruption of follow-up of ventricular septal defect （VSD）. A 35-year-old female was diagnosed with VSD immediately after birth and had been hospitalized twice for infective endocarditis in infancy and childhood. More than 10 years after the interruption of regular follow-up, she visited her family doctor with a chief complaint of shortness of breath on exertion and chest pain, and was referred to our hospital for evaluation of VSD. Echocardiography showed VSD and DCRV. VSD was as small as 5×4 mm, but the maximum flow velocity at the DCRV stenosis was 4.87 m/s, which was judged to be an indication for surgical treatment. The patient underwent right ventricular stenosis release through the right atrium. Postoperative right ventricular stenosis was resolved. Since adult cases of DCRV are rare, and there is a lack of awareness of the disease concept and the nonspecific symptoms, it is difficult to diagnose DCRV in adults; so it is therefore important to treat patients with this disease concept in mind. In addition, it might be necessary to maintain follow-up with patients even with small VSD.

   

  Jpn. J. Cardiovasc. Surg. 54: 207-211（2025）

  Keywords： double chambered right ventricle; ventricular septal defect; adult congenital heart disease

  
  
• ［Acquired Cardiovascular Surgery］
• A Case of Thoracic Aortopulmonary and Left Coronary Artery-Pulmonary Artery Fistulas with Aneurysms Treated with Coil Embolization, Aneurysm Resection, and Fistula Closure　Y. Furuyama et al. 　212
  A Case of Thoracic Aortopulmonary and Left Coronary Artery-Pulmonary Artery Fistulas with Aneurysms Treated with Coil Embolization, Aneurysm Resection, and Fistula Closure
  

  Yuria Furuyama＊	Kota Kawada＊	Toru Kameda＊
  Makoto Koyama＊	Tsubasa Yoshikawa＊	Erika Hanji＊＊
  Takahide Yao＊＊	Shinnosuke Okuma＊＊	Muneyasu Kawasaki＊＊＊
  Takeshiro Fujii＊

  
  

  (Department of Cardiovascular Surgery, Toho University Omori Medical Center＊, Tokyo, Japan, Department of Cardiovascular Surgery, Ikegami General Hospital＊＊, Tokyo, Japan, and Department of Cardiovascular Surgery, Misato Central General Hospital＊＊＊, Misato, Japan)
  

  A 66-year-old man with an abnormal electrocardiogram during a health examination sought evaluation at the cardiology department. Contrast-enhanced computed tomography （CT） revealed the presence of aneurysms　associated with aortopulmonary and left coronary artery-pulmonary artery fistulas. One of the identified aneurysms measured 20 mm. The patient was then referred to our department for surgical intervention. Although the patient was asymptomatic, surgery was planned due to the risk of rupture. Initially, coil embolization was performed to address the aortopulmonary fistula, which was followed by a median sternotomy. Intraoperatively, multiple tortuous abnormal vessels connecting both coronary arteries to the pulmonary artery were observed, along with aneurysms at the base of the pulmonary artery. The aneurysms were excised under cardiopulmonary bypass, and the opening of the pulmonary artery fistula was closed. Subsequent coronary angiography during surgery and postoperative cardiac CT confirmed the complete resolution of the abnormal vessels and aneurysms. The patient had an uneventful postoperative course and was discharged. We present the case of a patient with aneurysms associated with thoracic aortopulmonary and left coronary artery-pulmonary artery fistulas and review the relevant literature. The case was managed with a single-stage surgery involving coil embolization, aneurysm resection, and fistula closure.

   

  Jpn. J. Cardiovasc. Surg. 54: 212-215（2025）

  Keywords：Aortopulmonary fistula; coronary artery-pulmonary artery fistula; coronary aneurysm; hybrid therapy

  
  
• A Case of Chronic Expanding Intrapericardial Hematoma Presenting with Right Heart Failure 6 Years after Mitral Valve Replacement　T. Gondai et al.　216
  A Case of Chronic Expanding Intrapericardial Hematoma Presenting with Right Heart Failure 6 Years after Mitral Valve Replacement
  

  Tatsuro Gondai＊	Satoshi Numata＊	Takahisa Takahashi＊
  Tomohito Nakashima＊	Unpei Okamoto＊	Yusuke Yaku＊
  Shinichiro Oda＊

  
  

  (Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine＊, Kyoto, Japan)
  

  A 75-year old man presented with diuretic-resistant leg edema. He had a history of three cardiac surgeries: mitral valve plasty, mitral valve replacement with a stentless valve made of autologous pericardium, and mitral valve replacement with a mechanical prosthesis. Six years had passed since his last cardiac surgery. The tests revealed right heart failure due to a chronic expanding intrapericardial hematoma. The hematoma was removed via left thoracotomy, and which had been covered with the ePTFE pericardial membrane used in the previous chest closure was removed via left thoracotomy. The chronic expanding intrapericardial hematoma is a rare condition, and it was suggested that extensive coverage with the sheet may have been a contributing factor to its formation.

   

  Jpn. J. Cardiovasc. Surg. 54: 216-219（2025）

  Keywords：chronic expanding hematoma; cardiac surgery; ePTFE pericardial membrane

  
  
• A Case of Intermittent Dysfunction of a Mechanical Valve in Aortic Position　Y. Maniwa et al. 　220
  A Case of Intermittent Dysfunction of a Mechanical Valve in Aortic Position
  

  Yutaka Maniwa＊	Hirofumi Onitsuka＊	Kazuhiro Kurisu＊
  Yasutaka Ueno＊	Akira Shiose＊＊

  
  

  (Department of Cardiovascular Surgery, Shimonoseki City Hospital＊, Yamaguchi, Japan, and Department of Cardiovascular Surgery, Kyushu University Graduate School of Medicine＊＊, Fukuoka, Japan)
  

  A 53-year-old male with ankylosing spondylitis presented with worsening exertional dyspnea. Echocardiography revealed severe aortic regurgitation and an aortic valve replacement was performed using a mechanical valve （SJM Regent 21 mm） in consideration of his age. By the 5th postoperative week, the patient exhibited signs of worsening heart failure. On the 52nd postoperative day, intermittent prosthetic valve regurgitation was detected on echocardiography. Valve fluoroscopy revealed that the valve intermittently remained fixed in the open position, leading to a diagnosis of prosthetic valve dysfunction. Contrast-enhanced CT revealed no evidence of thrombus or tissue formation around the prosthetic valve. On the 56th postoperative day, a redo aortic valve replacement was performed with another mechanical valve （On-X 21 mm）. Intraoperatively, no obvious structural abnormalities were identified. Compression of the pivot may have contributed to the dysfunction. We report a rare complication associated with a mechanical prosthetic valve.

   

  Jpn. J. Cardiovasc. Surg. 54: 220-222（2025）

  Keywords：aortic regurgitation; aortic valve replacement; prosthetic valve dysfunction; mechanical valve

  
  
• Bentall Operation with Tricuspid Annuloplasty and Ligation of Persistent Left Superior vena cava after Repair of Tetralogy of Fallot in Situs Inversus Totalis　M. Ikebuchi et al. 　223
  Bentall Operation with Tricuspid Annuloplasty and Ligation of Persistent Left Superior vena cava after Repair of Tetralogy of Fallot in Situs Inversus Totalis
  

  Masahiko Ikebuchi＊	Yuki Kimura＊	Ryosuke Taki＊
  Kazutoshi Tano＊

  
  

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

  We report a case of a 52-year-old man with situs inversus totalis who underwent repair of tetralogy of Fallot in his childhood. He also experienced cerebral embolism at the age of 50 years, and recovered with no sequela after endovascular thrombectomy. Two years later, he was admitted to our hospital due to progressing orthopnea. He was diagnosed with congestive heart failure caused by severe aortic regurgitation with moderate tricuspid regurgitation and pulmonary hypertension. Three-dimensional computed tomography also showed aortic root dilation, single coronary artery, and inverse persistent left superior vena cava （PLSVC） draining into the left atrium, which was assumed to be associated with the previous stroke. A Bentall operation, tricuspid annuloplasty, and concomitant ligation of the PLSVC were performed.

   

  Jpn. J. Cardiovasc. Surg. 54: 223-227（2025）

  Keywords：Bentall operation; Tetralogy of Fallot; situs inversus totalis

  
  
• A Case of Aortic Valve Regurgitation with Subvalvular Aortic Stenosis and Extremely Small Annulus Treated with Left Ventricular Outflow Tract Myectomy with Y-incision Annular Enlargement and Aortic Valve Replacement　S. Kazama et al.　228
  A Case of Aortic Valve Regurgitation with Subvalvular Aortic Stenosis and Extremely Small Annulus Treated with Left Ventricular Outflow Tract Myectomy with Y-incision Annular Enlargement and Aortic Valve Replacement
  

  Shintaro Kazama＊	Yoshitsugu Nakamura＊	Yuto Yasumoto＊
  Kusumi Niitsuma＊	Taisuke Nakayama＊	Ryo Tsuruta＊
  Yujiro Ito＊	Yujiro Hayashi＊	Fumiaki Shikada＊＊

  
  

  (Department of Cardiovascular Surgery, Chiba-nishi General Hospital＊, Matsudo, Japan, and Department of Cardiovascular Surgery, The University of Tokyo Hospital＊＊, Tokyo, Japan)
  

  We report on a case of left ventricular outflow tract myectomy with Y-incision annular enlargement and aortic valve replacement for aortic valve regurgitation associated with subvalvular aortic stenosis. Subvalvular aortic stenosis is recognized as congenital heart disease, with a few reports in adult cases. Left ventricular outflow obstruction in cases of subvalvular aortic stenosis can be relieved by either the Konno procedure or a modified Konno procedure. Additionally, there has been an increasing number of reports of valve annular enlargement using the Y-incision technique recently. Unlike the Manouguian and Konno procedure, the Y-incision technique allows for valve annular enlargement without cutting the left atrium, mitral valve, or right ventricular outflow tract. While the Konno procedure would typically be considered for this case, the Y-incision technique was selected for valve annular enlargement. This approach provided a clear view from the aortic valve annulus, enabling the excision of fibrous thickening and abnormal myocardium excision. This case resulted in a favorable postoperative course.

   

  Jpn. J. Cardiovasc. Surg. 54: 228-232（2025）

  Keywords：subvalvular aortic stenosis; aortic valve regurgitation; annular enlargement

  
  
• A Case of Repeated Cardiac Trauma Caused by Sewing Needles　N. Oshiro et al. 　233
  A Case of Repeated Cardiac Trauma Caused by Sewing Needles
  

  Norikazu Oshiro＊	Takeshi Yoshida＊	Takuya Higuchi＊
  Takashi Kawashima＊＊

  
  

  (Department of Cardiovascular Surgery, Matsubara Tokushukai Hospital＊, Matsubara, Japan, and Department of Cardiovascular Surgery, Shonai Amarume Tokushukai Hospital＊＊, Yamagata, Japan)
  

  Here, we report a rare case of repeated cardiac trauma caused by self-harm with sewing needles and a literature review. The patient was a 48-year-old female, who repeatedly self-harmed when stressed by inserting a needle into her anterior chest. She had previously undergone three thoracotomy procedures and more than eight procedures for needle removal. In the current case, she visited the hospital due to persistent chest pain after inserting a needle into her left anterior chest. The needle was buried under the skin and could not be seen externally. Computed tomography revealed a 6 cm-long needle, located 1 cm under the skin reaching the right ventricle. Although the patient was hemodynamically stable with no pericardial effusion, emergency surgery was performed due to the possibility that cardiac motion would advance the needle, penetrating the left ventricle, as well as the possibility of additional cardiac injury. Because of repeated thoracotomies and needle-removal procedures, we expected that the patient would have extensive adhesions in the mediastinum, and there was a high risk of cardiac injury with thoracotomy. Therefore, thoracotomy was performed under cardiopulmonary bypass. We performed the thoracotomy while taking care not to advance the needle by monitoring its tip with transesophageal echocardiography. After confirming the position of the needle penetrating the right ventricle, 4-0 monofilament suture with pledget support was sutured around the needle in a U-shape, and the needle was removed. The procedure was completed after confirming the absence of ventricular septal perforation by transesophageal echocardiography.

   

  Jpn. J. Cardiovasc. Surg. 54: 233-236（2025）

  Keywords：heart injury; needle; self-injurious behavior; reoperation

  
  
• ［Aortic Disease］
• A Case of TAAA with a Short Distal Landing Zone Treated by Using the Staged Deployment of the Conformable TAG with ACTIVE CONTROL System　K. Manabe et al.　237
  A Case of TAAA with a Short Distal Landing Zone Treated by Using the Staged Deployment of the Conformable TAG with ACTIVE CONTROL System
  

  Kaichiro Manabe＊	Hidetake Kawajiri＊	Takuma Kobayashi＊
  Tomoya Inoue＊	Keiichi Kanda＊	Shinichiro Oda＊

  
  

  （Department of Cardiovascular Surgery, Kyoto Prefectural University of Medicine＊, Kyoto, Japan）
  

  An 89-year-old woman was followed with a diagnosis of thoracoabdominal aortic aneurysm （TAAA） with a diameter of 40 mm. Computed tomography （CT） scans revealed that the TAAA had rapidly expanded to 55 mm in diameter in just two years. She was admitted to our hospital. Considering her advanced age, conventional graft replacement was thought to be quite a high risk. Thus, we selected endovascular treatment. As the TAAA was located just above the celiac artery, it was necessary to deploy the stent-graft just proximal to the origin of the superior mesenteric artery in order to secure a sufficient distal landing zone. In this case, we could secure the maximum landing zone by using the endowedge technique with the staged deployment of the conformable TAG with ACTIVE CONTROL System. The postoperative course was uneventful, and CT disclosed complete occlusion of the aneurysm.

   

  Jpn. J. Cardiovasc. Surg. 54: 237-242（2025）

  Keywords：thoracoabdominal aortic aneurysm; thoracic endovascular aneurysm repair; conformable TAG with ACTIVE CONTROL System; endowedge technique

  
  
• A Case of Hemolytic Anemia Caused by a Kinked Graft after Surgery for Acute Aortic Dissection　T. Hirota et al. 243
  A Case of Hemolytic Anemia Caused by a Kinked Graft after Surgery for Acute Aortic Dissection
  

  Takafumi Hirota＊	Keijiro Inoue＊	Kosuke Nakata＊
  Tatsuya Horibe＊	Jun Takaki＊	Ken Okamoto＊
  Toshihiro Fukui＊

  
  

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

  The patient was a 63-year-old man. He underwent total arch replacement for Stanford type A acute aortic dissection. Eleven years after surgery, blood tests showed anemia, elevated LDH and direct bilirubin levels, and a visual blood test detected crushed red blood cells, leading to a diagnosis of hemolytic anemia. The Computed tomography showed a highly kinked graft, and the catheter test showed an increase in the pressure gradient before and after the kinked graft, suggesting that the patient had hemolytic anemia caused by the kinked graft. Because he also had moderate aortic regurgitation and a patent foramen ovale, he underwent resection of the kinked graft, ascending aortic replacement, aortic valve replacement, and closure of the foramen ovale. The postoperative course was good, and hemolytic anemia was not observed.

   

  Jpn. J. Cardiovasc. Surg. 54: 243-246（2025）

  Keywords：kinked graft; hemolytic anemia; acute aortic dissection; aortic regurgitation

  
  
• ［Peripheral Artery Disease］
• Renal Vascular Hypertension Improved by Revascularization of Iliac Artery Stenosis after Renal Transplantation　K. Watabe et al.　247
  Renal Vascular Hypertension Improved by Revascularization of Iliac Artery Stenosis after Renal Transplantation
  

  Kozue Watabe＊	Masamitsu Suhara＊	Kunihiro Shigematsu＊
  Yukio Obitsu＊

  
  

  （Department of Vascular Surgery, International University of Health and Welfare, Mita Hospital＊, Tokyo, Japan）
  

  Iliac artery stenosis associated with atherosclerosis after renal transplantation affects transplanted kidney function and graft kidney engraftment rate. We report a case of iliac artery revascularization for arteriosclerotic obliterans that improved renovascular hypertension and renal dysfunction. A 58-year-old male underwent a living donor renal transplant 20 years ago. He had experienced intermittent claudication in his right lower limb for 3 years. Computed tomography （CT） revealed severe stenosis of the right common iliac and femoral arteries because of a highly calcified plaque. The transplanted renal artery was anastomosed to the right external iliac artery. On admission, the patient had marked hypertension despite taking antihypertensive medication, and his plasma renin concentration was elevated to 126 pg/ml. Retrospectively, his serum creatinine concentration had increased from about one year earlier. Thus, the patient was diagnosed with renovascular hypertension and transplanted kidney dysfunction owing to reduced graft blood flow caused by proximal arterial stenosis. The patient underwent right common femoral artery thromboendarterectomy and endovascular treatment of both common iliac arteries resulting in a reduction in serum creatinine and plasma renin concentrations and blood pressure, in addition to an improvement in intermittent claudication. We hypothesized that iliac artery stenosis is an infrequent but important postoperative complication that should be considered when graft blood flow is suspected to decrease after kidney transplantation.

   

  Jpn. J. Cardiovasc. Surg. 54: 247-250（2025）

  Keywords：arteriosclerosis obliterans, iliac artery stenosis; renal transplantation; renovascular hypertension; revascularization

  
  

Progress in Cardiovascular Surgery (2024)

• Progress in the Field of Minimally Invasive Cardiac Therapies in 2024　J. Ito　251
• Update of 2024 in Peripheral Artery Disease　K. Morisaki　255

U-40

• U-40 Column
• Domestic Fellowship Training for Young Cardiovascular Surgeons in Japan: Current Trends and Observations　T. Nagase et al. 　U1
  Domestic Fellowship Training for Young Cardiovascular Surgeons in Japan: Current Trends and Observations
  

  Takashi Nagase*	Takanori Tsujimoto	Hisayuki Hongu
  Kohei Tonai	Yuta Kitakata	Kazuki Noda

  
  

  (Department of Cardiovascular Surgery, Fukui Cardiovascular Center*, Fukui, Japan)
  

  This article provides an overview of the current situation regarding domestic fellowships for young cardiovascular surgeons in Japan, based on the author’s personal experience and the results of a nationwide survey. The author undertook a one-year domestic fellowship beginning in April 2023 at the Department of Cardiovascular Surgery, Fukuoka Children’s Hospital. In addition to gaining extensive experience in pediatric cardiac surgery, the author had opportunities to engage in clinical research and present at academic conferences. Conducting research alongside hands-on clinical training offered valuable insights and deepened the author’s understanding of various cardiac conditions. At the same time, practical considerations such as relocating with family and establishing childcare support systems required careful planning. Furthermore, a survey targeting U40 committee members was conducted to investigate the motivations, outcomes, and challenges associated with domestic fellowships. The results revealed that many young surgeons viewed domestic fellowships positively, citing benefits such as diverse clinical experience, acquisition of new knowledge, and the development of professional networks. However, several barriers were also identified, including limited access to information, personnel constraints due to institutional staffing systems, and disruptions to personal and family life. The findings suggest that enhanced cross-institutional support and improved information sharing are essential to facilitate the development of young surgical talent in Japan.

   

  Jpn. J. Cardiovasc. Surg. 54(5): U1-U5 (2025).

  
  

Editor’s Post Script

• D. Akamatsu