JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 54, No. 6, November 2025 CONTENTS

Preface

• The Needs of Vascular Surgical Training　H. Komai

Original

• Duration of Early Preoperative Incentive Spirometry and Its Impact on Postoperative Pulmonary Complications in Patients Undergoing Open-Heart Surgery　K. Ishikawa et al.　257
  Duration of Early Preoperative Incentive Spirometry and Its Impact on Postoperative Pulmonary Complications in Patients Undergoing Open-Heart Surgery
  

  Kyohei Ishikawa＊	Mio Kasai＊＊	Kenichi Hashizume＊＊

  
  

  (Department of Rehabilitation Technology＊, and Department of Cardiovascular Surgery＊＊, Saiseikai Utsunomiya Hospital, Utsunomiya, Japan)
  

  Introduction: While some reports have described the use of incentive spirometry （IS） beginning a few days prior to cardiac surgery, there is a lack of studies investigating its implementation from an earlier preoperative period. Furthermore, the relationship between the duration of preoperative IS use and the incidence of postoperative pulmonary complications （PPCs） remains unclear. Therefore, this study aimed to clarify the impact of different durations of preoperative IS use on postoperative outcomes, particularly the incidence of PPCs. Methods: A total of 91 patients who underwent elective cardiac surgery at our institution were included. Preoperative IS instruction was provided, and the duration from the initiation of IS to the day of surgery was recorded. Patients were divided into two groups: the short-term IS group （≤14 days, n＝17） and the long-term IS group （≥15 days, n＝74）. Postoperative outcomes and the incidence of PPCs were compared between the two groups. Results: Compared to the short-term IS group （n＝17）, the long-term IS group （n＝74） had a significantly lower incidence of postoperative pulmonary complications （47.0% vs. 17.5%, p＜0.05）, and fewer days to achieve sitting （3 vs. 2 days）, standing （4 vs. 4 days）, and walking （6 vs. 4 days） （p＜0.05）. Additionally, the long-term group showed significantly better outcomes at discharge in terms of physical function （SPPB: 9 vs. 12）, functional status （FSS-ICU: 33 vs. 35, p＜0.01）, and discharge disposition （transfer to another hospital: 35.2% vs. 9.4%, p＜0.05）. Conclusion: Initiating IS instruction more than two weeks prior to cardiac surgery may reduce the incidence of postoperative pulmonary complications and contribute to earlier mobilization and better postoperative physical function.

   

  Jpn. J. Cardiovasc. Surg. 54: 257-262（2025）

  Keywords：incentive spirometry; prehabilitation; postoperative pulmonary complications

  
  

Case Reports

• ［Acquired Cardiovascular Surgery］
• Mitral Regurgitation in Which Posterior Leaflet Prolapse Occurred during Follow-up of Hypertrophic Obstructive Cardiomyopathy　D. Sato et al.　263
  Mitral Regurgitation in Which Posterior Leaflet Prolapse Occurred during Follow-up of Hypertrophic Obstructive Cardiomyopathy
  

  Daiki Sato＊	Masato Nakajima＊	Ikumi Osawa＊
  Takahito Yokoyama＊	Yasutoshi Tsuda＊

  
  

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

  A 65-year-old man was diagnosed with hypertrophic cardiomyopathy 11 years previously. Five years previously, he was hospitalized for pneumonia and heart failure and mitral regurgitation（MR） occurred due to systolic anterior motion（SAM） of the mitral valve. Two months previously, he was admitted for cardioembolic stroke, and echocardiography showed that SAM had disappeared. However, severe MR owing to posterior leaflet prolapse was observed. Mitral valvuloplasty, ventricular septal myectomy, pulmonary vein isolation, and left atrial appendage closure were performed. Postoperative echocardiography revealed no SAM and the patient was doing well. Here, we report a rare case of MR due to chordae rupture during follow-up of hypertrophic obstructive cardiomyopathy.

   

  Jpn. J. Cardiovasc. Surg. 54: 263-266（2025）

  Keywords：mitral regurgitation; systolic anterior motion; hypertrophic obstructive cardiomyopathy

  
  
• Right-Sided Infective Endocarditis with Jet Lesion-Induced Right Ventricular Vegetations Associated with Ventricular Septal Defect　K. Kitamura et al.　267
  Right-Sided Infective Endocarditis with Jet Lesion-Induced Right Ventricular Vegetations Associated with Ventricular Septal Defect
  

  Kohei Kitamura＊	Daiki Sakurai＊	Yutaro Tanigawa＊
  Takayuki Saito＊

  
  

  (Department of Cardiovascular Surgery, Kariya Toyota General Hospital＊, Kariya, Japan)
  

  Right-sided infective endocarditis （RSIE） localized to the right ventricular free wall is rare, and surgical excision of vegetations in such cases has seldom been reported. We describe a case of RSIE with the vegetations on the right ventricular free wall associated with ventricular septal defect （VSD） that was successfully treated with surgical intervention at an appropriate timing. The patient was a 30-year-old woman who had been diagnosed with a VSD shortly after birth. No surgical treatment had been performed and she had been followed conservatively. She was emergently transported to our hospital with disturbed consciousness caused by water intoxication due to psychogenic polydipsia. On admission, she presented with severe hyponatremia and elevated inflammatory markers. CT was performed, showing multiple bilateral pulmonary infiltrates, which were initially suspected to be pneumonia. After admission, blood cultures yielded Streptococcus mitis, and echocardiography showed two mobile vegetations on the right ventricular free wall, corresponding to a jet lesion caused by the VSD, leading to the diagnosis of RSIE. Subsequent contrast-enhanced CT showed filling defects in both pulmonary arteries, and septic pulmonary embolism （SPE） was diagnosed. Although antibiotic therapy improved inflammatory findings, the patient had a history of IE, which itself was an indication for VSD closure. In addition, we observed newly emerging, albeit minor, infiltrates in the lung fields. Therefore, we decided to proceed with elective surgery at that point. The vegetations on the right ventricular free wall was excised, the VSD was closed with an expanded polytetrafluoroethylene （ePTFE） patch, and the atrial septal defect incidentally found during surgery was also closed with direct sutures. Pathological examination of the excised specimen confirmed the infective vegetations. Including the period of postoperative oral antibiotic therapy, the total duration of antibiotic treatment was eight weeks. Her postoperative course was uneventful, and no recurrence was observed at 3 months after surgery.

   

  Jpn. J. Cardiovasc. Surg. 54: 267-270（2025）

  Keywords：ventricular septal defect; right-sided infective endocarditis; septic pulmonary embolism

  
  
• Trans-Tricuspid Double-Patch Closure of Chronic Posterior Ventricular Septal Rupture　Y. Nishida et al.　271
  Trans-Tricuspid Double-Patch Closure of Chronic Posterior Ventricular Septal Rupture
  

  Yuji Nishida＊	Naoki Saito＊	Akira Murata＊＊
  Hirofumi Takemura＊＊

  
  

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

  A 77-year-old woman presented three months after an inferior myocardial infarction with congestive heart failure, a 7-mm posterior ventricular septal rupture （VSR）, moderate functional mitral and tricuspid regurgitation, and critical stenoses of the right coronary and circumflex arteries. To avoid a ventriculotomy, we repaired the defect through a trans-tricuspid right-atrial approach using a double 25×25 mm bovine-pericardial patch secured with eight 4-0 polypropylene vertical mattress sutures. Two-vessel coronary artery bypass grafting was completed on the beating heart, followed by mitral and tricuspid annuloplasty. Cardiopulmonary bypass and aortic cross-clamp times were 231 and 113 min, respectively. The postoperative course was uneventful without mechanical circulatory support. Echocardiography confirmed complete closure of the VSR and elimination of both valvular regurgitations, and the patient was discharged home on postoperative day 30. This case illustrates that a trans-tricuspid double-patch technique can achieve secure closure of chronic posterior VSR while preserving ventricular function and permitting simultaneous valve repair and revascularization.

   

  Jpn. J. Cardiovasc. Surg. 54: 271-275（2025）

  Keywords：posterior ventricular septal rupture; trans-tricuspid approach; double-patch repair; coronary artery bypass; mitral-tricuspid annuloplasty

  
  
• Totally Endoscopic 3D Mitral Valve Plasty for a Patient with Loeys-Dietz Syndrome Type 3 and a Narrow Chest　R. Tohma et al.　276
  Totally Endoscopic 3D Mitral Valve Plasty for a Patient with Loeys-Dietz Syndrome Type 3 and a Narrow Chest
  

  Ryo Tohma＊	Hidekazu Nakai＊	Akitoshi Yamada＊
  Yoshihisa Morimoto＊	Kunio Gan＊	Tatsuro Asada＊

  
  

  (Department of Cardiovascular Surgery, Kita-Harima Medical Center＊, Ono, Japan)
  

  Loeys-Dietz syndrome （LDS） is a rare genetic disorder characterized by systemic connective tissue abnormalities. Among its subtypes, LDS type 3 is associated with SMAD3 gene mutations and often presents with vascular and skeletal abnormalities. Narrow chest is a relative contraindication for minimally invasive cardiac surgery （MICS）, yet this approach can be advantageous in connective tissue disorders where repeated surgeries may be anticipated. A 63-year-old woman with a previously unreported SMAD3 variant was diagnosed with LDS type 3. She presented with severe mitral regurgitation due to A2-3 prolapse. Her skeletal features included a narrow chest （anteroposterior diameter: 5 cm）, scoliosis, and pectus excavatum. Totally endoscopic 3D mitral valve plasty was performed via a right minithoracotomy using a 2-port, 1-window approach. Mitral repair was successfully completed using artificial chordae and ring annuloplasty. Adequate exposure was achieved despite the narrow chest by retracting the pericardium and displacing the aorta using gauze packing. The mitral valve was clearly visualized using the 3D endoscopic camera, allowing safe repair of the A2-3 prolapse with four artificial chordae and a 29-mm Tailor ring. The patient was extubated 3.5 hours postoperatively and had an uneventful recovery except for transient atrial fibrillation. She was discharged on postoperative day 13 in sinus rhythm. Totally endoscopic MICS-MVP is feasible and beneficial even in patients with challenging thoracic anatomy due to connective tissue disease. It enables chest wall preservation and minimizes surgical trauma, which is particularly advantageous for LDS patients with lifelong surgical risk.

   

  Jpn. J. Cardiovasc. Surg. 54: 276-279（2025）

  Keywords：Loeys-Dietz syndrome; SMAD3; narrow chest; MICS; mitral valve repair

  
  
• A Case of a Metastatic Cardiac Tumor with Left Ventricular Outflow Tract Stenosis Treated with Tumor Resection Using the MICS Transmitral Approach　T. Kurashiki et al.　280
  A Case of a Metastatic Cardiac Tumor with Left Ventricular Outflow Tract Stenosis Treated with Tumor Resection Using the MICS Transmitral Approach
  

  Tomohiro Kurashiki＊	Kazuma Yamane＊	Yuki Otsuki＊
  Shingo Harada＊＊	Yoshinobu Nakamura＊

  
  

  （Department of Cardiovascular Surgery, Matsue Red Cross Hospital＊, Matsue, Japan, and Department of Cardiovascular Surgery, Matsue City Hospital＊＊, Matsue, Japan）
  

  The patient is an 81-year-old woman diagnosed with a metastatic cardiac tumor and left ventricular outflow tract stenosis. Due to the high risk of sudden death associated with tumor ablation, an emergency tumor resection was performed. The patient exhibited cancer cachexia and was in a highly frail state. There were concerns about delays in postoperative recovery and chemotherapy; hence, minimally invasive cardiac surgery was performed via a transmitral approach. To secure the visual field, a longitudinal incision was made at the anterior apex of the mitral valve. The visualization was excellent; thus, the tumor could be easily resected. This report highlights the effectiveness of the transmitral approach for accessing a cardiac tumor located in the middle of the left ventricular septum and reviews relevant literature.

   

  Jpn. J. Cardiovasc. Surg. 54: 280-283（2025）

  Keywords：metastatic cardiac tumor; minimally invasive cardiac surgery; left ventricular tumor; transmitral approach

  
  
• A Case of Surgical Removal of a Central Venous Catheter Guidewire Entrapped in the Chiari Network　Y. Tanabe et al.　284
  A Case of Surgical Removal of a Central Venous Catheter Guidewire Entrapped in the Chiari Network
  

  Yuriko Tanabe＊	Motohiko Osako＊	Shuichiro Yoshitake＊

  
  

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

  The Chiari network is a fenestrated embryologic remnant in the right atrium, usually asymptomatic but occasionally involved in catheter entrapment. We report a rare case where a central venous catheter guidewire became entangled in the Chiari network and required surgical removal. A 68-year-old woman scheduled for off-pump coronary artery bypass surgery （OPCAB） underwent preoperative central venous catheter placement via the right internal jugular vein. During the procedure, resistance was encountered upon withdrawal of the guidewire. Intraoperative echocardiography and fluoroscopy revealed the tip of the guidewire in the right atrium. As traction resulted in significant resistance, we proceeded with surgical removal after completion of the bypass grafting. Under cardiopulmonary bypass, the right atrium was opened, revealing fibrous strands entangling the guidewire, consistent with a Chiari network. The entangled portion was excised, and the guidewire was safely removed without damage to adjacent structures. This case highlights the importance of considering Chiari network entrapment as a differential diagnosis when encountering resistance during central venous catheter placement. Surgical intervention should be considered when percutaneous retrieval is not feasible.

   

  Jpn. J. Cardiovasc. Surg. 54: 284-287（2025）

  Keywords：Chiari network; central venous catheter; guidewire entrapment; right atrium

  
  
• ［Aortic Disease］
• A Case of Retrograde Acute Type A Aortic Dissection Treated with Total Arch Replacement and Thoracic Endovascular Aortic Repair　T. Nakagawa et al.　288
  A Case of Retrograde Acute Type A Aortic Dissection Treated with Total Arch Replacement and Thoracic Endovascular Aortic Repair
  

  Taku Nakagawa＊	Koki Yokawa＊	Makoto Kusakisako＊
  Tomonori Higuma＊	Yosuke Tanaka＊	Kazunori Yoshida＊
  Yoshihiro Oshima＊	Hidefumi Obo＊	Hidetaka Wakiyama＊

  
  

  （Department of Cardiovascular Surgery, Kakogawa Central City Hospital＊, Kakogawa, Japan）
  

  The treatment strategy for acute type A aortic dissection consists of entry closure and maximal resection of the dissected aortic segment. In cases where the entry is located in the distal descending aorta, as in this case, entry closure is challenging, and surgery often involves only maximal resection of the dissected segment. The patient was a 53-year-old man who presented with sudden onset of chest pain. CT revealed a retrograde Stanford type A acute aortic dissection with a tear in the distal descending aorta. Preoperative measurements suggested that entry closure using frozen elephant trunk（FET）would be impossible. Surgery was performed with the goal of maximal resection of the dissected aortic segment in a hybrid operating room. The patient underwent total arch replacement（TAR）using FET. TEE revealed true lumen stenosis beyond the descending aorta, along with a decrease in lower limb blood pressure reducing blood flow to the abdominal branches. Therefore, emergency TEVAR was performed to achieve entry closure in the entire descending aorta. After TEVAR, the true lumen expanded, and perfusion to the lower limbs and abdominal branches improved. The postoperative course was uneventful, and the patient was discharged on postoperative day 10.

   

  Jpn. J. Cardiovasc. Surg. 54: 288-291（2025）

  Keywords：retrograde acute aortic dissection; thoracic endovascular aortic repair; total arch replacement; frozen elephant trunk

  
  
• A Case Report of Surgery for Active Infected Thoracic Aortic Aneurysm Complicated with True Abdominal Aortic Aneurysm　A. Tamenishi et al.　292
  A Case Report of Surgery for Active Infected Thoracic Aortic Aneurysm Complicated with True Abdominal Aortic Aneurysm
  

  Akinori Tamenishi＊	Sho Akita＊	Yasumoto Matsumura＊

  
  

  （Department of Cardiovascular Surgery, Yokkaichi Municipal Hospital＊, Yokkaichi, Japan）
  

  A 64-year-old man was followed up for an abdominal aortic aneurysm （AAA）, 40 mm in diameter. The patient was admitted due to sudden onset left shoulder pain, fever, and an elevated serum C-reactive protein （CRP） level. Enhanced computed tomography （CT） revealed a deep neck abscess and an infected thoracic aortic aneurysm. The deep neck abscess improved after drainage. Antibiotics were administered for one month, but the fever and elevated CRP level persisted. Subsequent CT revealed an increased diameter of the thoracic aorta. Due to an actively infected thoracic aortic aneurysm, an extra-anatomical bypass from the ascending aorta to the left carotid artery and the left axillary artery was performed, a graft prosthesis replaced the AAA, a main graft of extra-anatomical bypass was anastomosed laterally to the replaced graft prosthesis of AAA, and the infected thoracic aorta was resected. Administration of antibiotics was terminated eight weeks post-surgery. The patient had no recurrence of infection while free of antibiotics for 10 years.

   

  Jpn. J. Cardiovasc. Surg. 54: 292-296（2025）

  Keywords：infected thoracic aortic aneurysm; abdominal aortic aneurysm; extra-anatomical bypass

  
  

Progress in Cardiovascular Surgery (2024)

• Advances in the Congenital Heart Disease　N. Oka　297

U-40

• U-40 Column
• Progress and Future Perspectives of the U-40 Basic Lecture Course Hands-on Seminar in the Post-COVID-19 Era: Experience from the Hokkaido Branch　H. Uchiyama et al.　U1
  Progress and Future Perspectives of the U-40 Basic Lecture Course Hands-on Seminar in the Post-COVID-19 Era: Experience from the Hokkaido Branch
  

  Hiroki Uchiyama＊	Masato Fusegawa	Takamitsu Tatsukawa
  Ayaka Arihara	Naohiro Wakabayashi	Ryosuke Numaguchi
  Hiroyuki Miyamoto	Yoshinobu Watabe	Kei Mukawa
  Kohei Ishido	Masato Yonemori	Daiki Ito
  Yuto Oguma

  
  

  （Department of Cardiovascular Surgery, Sapporo Shiroishi Memorial Hospital, Sapporo, Japan）
  

  The Basic Lecture Course (BLC）hands-on seminar has long been a core educational activity organized by the U-40 of the Japanese Society for Cardiovascular Surgery at the branch level. However, due to the COVID-19 pandemic, in-person seminars were suspended for an extended period. Since 2022, the seminars have gradually resumed, and in 2025, a branch-based hosting system was introduced. Nevertheless, several challenges unique to the post-pandemic era have become evident. In the Hokkaido Branch, BLC hands-on seminars were held in July 2024 and August 2025. This report presents the outlines and management processes of these two events, summarizes the results of participant surveys, and discusses future challenges and perspectives for the operation of BLC hands-on seminars.

   

  Jpn. J. Cardiovasc. Surg. 54(6): U1-U5 (2025).

  
  

Editor’s Post Script

• T. Uchida