JAPANESE JOURNAL OF CARDIOVASCULAR SURGERY Editor in Chief : Yoshikatsu Saiki Vol. 55, No. 3, May 2026 CONTENTS

Preface

• Cardiovascular and Vascular Surgery as a Career Path in an Era of Physician Oversupply　K. Hoshina

Case Reports

• ［Congenital Heart Disease］
• Intraoperative Coronary Artery Dissection during Pulmonary Valve Replacement after Repair of Tetralogy of Fallot　M. Sugano et al.　99
  Intraoperative Coronary Artery Dissection during Pulmonary Valve Replacement after Repair of Tetralogy of Fallot
  

  Mikio Sugano＊	Yuki Kimura＊	Ryota Matsumoto＊
  Masaki Yamamoto＊	Takashi Kitaichi＊	Hiroki Hata＊

  
  

  (Department of Cardiovascular Surgery, Institute of Biomedical Sciences, The University of Tokushima Graduate School＊, Tokushima, Japan)
  

  Surgical intervention was recommended for a 31-year-old woman with pulmonary regurgitation after intracardiac repair of Tetralogy of Fallot. Using a cardiopulmonary bypass with the heart beating, surgery was performed to replace the pulmonary valve. Transesophageal echocardiography revealed mildly decreased right ventricular systolic function after weaning from cardiopulmonary bypass. While careful inspection of the right coronary artery revealed no macroscopic abnormalities, during chest closure, the patient developed refractory ventricular fibrillation, requiring frequent defibrillation and reinitiation of cardiopulmonary bypass. The patient showed a marked decrease in right ventricular function, indicating severe coronary ischemia. Epicardial echocardiography was performed to assess the coronary arteries. Although no dissection was detected at the aortic root, including the cannulation site, dissection of the right coronary artery was confirmed. The patient was transferred to a hybrid operating room where coronary angiography and intravascular ultrasonography （IVUS） were performed, revealing extensive coronary artery dissection, with an initial entry near the right coronary artery ostium. The underlying cause was compression of the true lumen by the false lumen. Blood flow was significantly improved by creating a reentry channel to the distal part of the right coronary artery. The patient’s sinus rhythm subsequently returned, and her hemodynamics stabilized, allowing successful weaning from cardiopulmonary bypass. No ischemic symptoms or ventricular arrhythmias have occurred since the surgery, and cardiac function is currently good. In this case, no direct intervention was performed on the coronary arteries. However, because the right coronary artery originated slightly to the left of the normal artery, the possibility that intraoperative mechanical stimulation may have caused the condition could not be ruled out. Although this is an extremely rare condition, prompt and accurate pathological evaluation and treatment led to a favorable outcome.

   

  Jpn. J. Cardiovasc. Surg. 55: 99-102（2026）

  Keywords：coronary artery; dissection; intraoperative

  
  
• ［Acquired Cardiovascular Surgery］
• Two Cases of Reoperation due to Structural Valve Failure after Aortic Valve Replacement by Mechanical Valve　M. Noda et al.　103
  Two Cases of Reoperation due to Structural Valve Failure after Aortic Valve Replacement by Mechanical Valve
  

  Mika Noda＊	Yoshimori Araki＊	Akihiro Kobayashi＊
  Eriko Koike＊	Osamu Kawaguchi＊

  
  

  (Department of Cardiac Surgery, Toyota Kosei Hospital＊, Toyota, Japan)
  

  Although mechanical prosthetic valves are highly durable and designed for permanent function, complications such as valve dysfunction due to thrombus or pannus formation, and infection may occasionally occur. We present two cases of prosthetic valve dysfunction caused by pannus formation following mechanical aortic valve replacement（AVR）requiring re-do surgery. Case 1 was 74-year-old women with annular injury and repair at initial AVR. Twenty-six years later, restricted motion of one leaflet developed, re-do AVR with bioprosthesis, annular reconstruction, and ST junction enlargement was performed. Case 2 was a 74- year- old woman with aortic injury and valve re-attachment at initial AVR. Thirteen years after later, she underwent re-do AVR with bioprosthesis, annular and ST junction enlargement, and the Morrow procedure for leaflet restriction. In both cases, pannus formation around the prosthetic annulus caused leaflet restriction and valve dysfunction. Risk factors include female sex, pregnancy, infective endocarditis, small annulus, and poor preservation of subvalvular tissue. In particular, irregularity of the annulus and additional surgical procedures may promote pannus formation. In these cases, both patients were female, and additional procedures to the annulus had been performed at the initial operation; therefor they were considered to have met the risk factors for pannus formation. In patients with such risk, attention should be paid to valve dysfunction associated with pannus formation, and appropriate follow-up and early surgical intervention are required.

   

  Jpn. J. Cardiovasc. Surg. 55: 103-106（2026）

  Keywords：mechanical valves; structural valve failure; re-valve replacement surgery

  
  
• A Case of Idiopathic Calcified Amorphous Tumor Found as a Calcified Spherical Tumor in the Right Atrium　M. Kotani et al.　107
  A Case of Idiopathic Calcified Amorphous Tumor Found as a Calcified Spherical Tumor in the Right Atrium
  

  Mitsuhisa Kotani＊	Akihito Kagoshima＊	Hiroki Yamaguchi＊＊
  Kosuke Onaka＊＊	Kazuhiko Higuchi＊	Yasushi Akutsu＊＊＊
  Tenei Ko＊

  
  

  (Cardiovascular Surgery （Cardiology）, Kashima Heart Clinic＊, Kashima, Japan, Cardiovascular Surgery, Showa University Koto Toyosu Hospital＊＊, Tokyo, Japan, and Department of Cardiology, Showa University Hospital＊＊＊, Tokyo, Japan)
  

  The patient was 63-year-old female who had no past history nor structural heart disease. She had an episode of pre-syncope with dyspnea. Echocardiography showed a highly mobile and calcified spherical mass in the right atrium. Contrast-enhanced cardiac computed tomography also showed a calcified tumor along the right atrial wall. Urgent surgery was performed considering the risks of pulmonary embolism and obstruction of the tricuspid valve by the tumor. The tumor in the right atrium was removed surgically under cardiopulmonary bypass. The postoperative course was uneventful, and the patient was discharged on day 10. Histopathological finding was fibrous tissue with nodular calcification which was consistent with calcified amorphous tumor.

   

  Jpn. J. Cardiovasc. Surg. 55: 107-110（2026）

  Keywords：right atrium; calcified amorphous tumor; idiopathic cardiac mass

  
  
• A Case of Coronary Artery Bypass Grafting for Angina in a Patient with Evans Syndrome　H. No et al.　111
  A Case of Coronary Artery Bypass Grafting for Angina in a Patient with Evans Syndrome
  

  Hironari No*	Hiroki Kato*	Masaki Kitazawa*

  
  

  （Cardiovascular Surgery, Ishikawa Prefectural Central Hospital*, Kanazawa, Japan）
  

  The patient was a 78-year-old man with a history of idiopathic thrombocytopenic purpura （ITP） in remission, who was admitted with symptoms of angina. Upon admission, he developed rapidly worsening anemia, and further evaluation revealed autoimmune hemolytic anemia （AIHA）, leading to a diagnosis of Evans syndrome. His anemia improved with blood transfusion and corticosteroid therapy, and he subsequently underwent elective coronary artery bypass grafting （CABG） with percutaneous cardiopulmonary support （PCPS）. Postoperatively, corticosteroids were administered under the guidance of the hematology department, and he was discharged in good condition without any complications related to anemia or bleeding. This report presents a literature-based discussion on the perioperative risks and management strategies for immunosuppressed patients.

   

  Jpn. J. Cardiovasc. Surg. 55: 111-115（2026）

  Keywords：Evans syndrome; autoimmune hemolytic anemia; idiopathic thrombocytopenic purpura; steroids; coronary artery bypass grafting

  
  
• A Case of Double Orifice Mitral Valve with Mitral Valve Regurgitation Repaired by Minimally Invasive Cardiac Surgery　K. Iizuka et al.　116
  A Case of Double Orifice Mitral Valve with Mitral Valve Regurgitation Repaired by Minimally Invasive Cardiac Surgery
  

  Kei Iizuka＊, ＊＊	Masaru Kambe＊	Kozo Morita＊＊
  Hiroshi Niinami＊＊

  
  

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

  A 70-year-old woman was diagnosed with mitral valve regurgitation during preoperative evaluation for another disease. Echocardiography revealed severe mitral valve regurgitation with posterior leaflet prolapse, and surgery was deemed appropriate. In addition to regurgitation, partial opening restriction was observed, but no abnormalities in other valves or intracardiac malformations were found. The surgery was performed under minimally invasive cardiac surgery （MICS）. During the procedure, a double orifice mitral valve （DOMV） was diagnosed. The bridging tissue was excised, and the mitral valve was repaired using artificial chordae and a mitral valve annulus band. DOMV is a very rare congenital anomaly of the mitral valve, and while its difficulty in preoperative diagnosis and wide range of clinical courses have been reported, the number of cases remains small. This is a valuable case report of successful repair performed via MICS.

   

  Jpn. J. Cardiovasc. Surg. 55: 116-120（2026）

  Keywords：double orifice mitral valve; mitral valve repair; minimal invasive cardiac surgery; congenital heart disease; mitral valve regurgitation

  
  
• A Case of DIC Caused by a Giant Left Ventricular Pseudoaneurysm Requiring Urgent Surgery　A. Matsumoto et al.　121
  A Case of DIC Caused by a Giant Left Ventricular Pseudoaneurysm Requiring Urgent Surgery
  

  Atsushi Matsumoto＊	Keiichiro Kasama＊	Yasuko Uranaka＊
  Naoya Yamashita＊	Takehiro Kato＊

  
  

  （Department of Cardiovascular Surgery, Yokohama Municipal Citizen’s Hospital＊, Yokohama, Japan）
  

  The patient was a 52-year-old woman. Following myocardial infarction and pericarditis involving the diagonal branch, follow-up transthoracic echocardiography revealed a left ventricular aneurysm. Due to its enlarging trend, elective surgery was considered. However, she was admitted to our hospital urgently for acute heart failure. Laboratory tests showed that elevated inflammation markers and thrombocytopenia, suggesting disseminated intravascular coagulation （DIC）. Further examination ruled out infection as a cause and determined that thrombus in the left ventricular aneurysm had triggered the DIC. Urgent surgery was performed to prevent aneurysm rupture and treat the DIC. A large amount of thrombus was found in the aneurysm. The postoperative diagnosis was a pseudoaneurysm due to infarction-cardiac rupture. Septal Anterior Ventricular Exclusion （SAVE） procedure was performed. Postoperatively DIC gradually improved, and the patient was discharged with a generally uneventful postoperative course. She is currently undergoing outpatient follow-up. This case was a rare one in which DIC was caused by a massive thrombus in the left ventricular aneurysm. Although the coagulopathy was present, urgent surgery was required to treat the DIC.

   

  Jpn. J. Cardiovasc. Surg. 55: 121-127（2026）

  Keywords：left ventricular aneurysm; pseudoaneurysm; DIC; massive thrombus; SAVE surgery

  
  
• Effect of IMPELLA 5.5 SmartAssist after Emergency Repair of a Blowout-Type Left Ventricular Free Wall Rupture　D. Komatsu et al.　128
  Effect of IMPELLA 5.5 SmartAssist after Emergency Repair of a Blowout-Type Left Ventricular Free Wall Rupture
  

  Daisuke Komatsu＊	Tomohiro Takano＊	Kazuki Naito＊
  Yu Matsumura＊	Tetsuya Kono＊

  
  

  (Department of Cardiovascular Surgery, Nagano Red Cross Hospital＊, Nagano, Japan)
  

  A 79-year-old man presented to our hospital with a sudden loss of consciousness and chest pain. The patient was in shock with vital signs, and echocardiography revealed severe hypokinesis from the apex to the anterior left ventricular wall and massive pericardial effusion. The patient was diagnosed with cardiac tamponade, and pericardial drainage and coronary angiography were performed immediately. Results showed that the patient had oozing-type left ventricular free wall rupture associated with acute myocardial infarction of anterior descending branch #7. After percutaneous coronary intervention, an IMPELLA CP SmartAssist was inserted to induce remodeling through left ventricular decompression. However, massive bleeding and difficulty in maintaining circulation led to the decision for emergency surgery. Intraoperative findings included extensive necrosis of the apex region and perforation of the peripheral region of the anterior descending branch. Hemostasis was achieved with two felt pledget-armed sutures after the application of hemostatic agents to the bleeding site using a sutureless technique. Subsequently, the graft was sutured to the ascending aorta, and the IMPELLA 5.5 SmartAssist was introduced using the direct aortic implantation technique. Immediately postoperatively, the patient was IMPELLA 5.5-dependent, but his cardiac function gradually improved. He was extubated on postoperative day 13 and weaned off the IMPELLA 5.5 on postoperative day 16. The patient was transferred for rehabilitation on postoperative day 68. Although the mortality rate of blowout-type left ventricular free wall rupture is still high, the use of IMPELLA 5.5 after emergency surgery may be an effective treatment option in terms of myocardial recovery and prevention of postoperative bleeding.

   

  Jpn. J. Cardiovasc. Surg. 55: 128-131（2026）

  Keywords：left ventricular free wall rupture; blowout-type; IMPELLA

  
  
• ［Aortic Disease］
• A Case of Type A Aortic Dissection with Single Coronary Artery after Aortic Valve Replacement　C. Yokoyama et al.　132
  A Case of Type A Aortic Dissection with Single Coronary Artery after Aortic Valve Replacement
  

  Chihiro Yokoyama＊	Noriyuki Takashima＊	Kei Saito＊
  Yoshitaka Tsuchida＊	Yuki Tokumochi＊	Taku Tanaka＊
  Kentaro Matsuoka＊	Shintaro Okuda＊	Fumihiro Miyashita＊
  Tomoaki Suzuki＊

  
  

  (Division of Cardiovascular Surgery, Department of Surgery, Shiga University of Medical Science＊, Otsu, Japan)
  

  A 56-year-old woman with a history of aortic valve replacement was incidentally found to have a DeBakey type II aortic dissection of unknown onset during routine follow-up. Preoperative computed tomography angiography showed that single coronary artery origin of the right coronary sinus. The left coronary artery with an interarterial course was suspected to have proximal stenosis or intramural segment. She had no ischemic symptoms prior to surgery. A redo sternotomy and ascending aortic replacement was performed while preserving the previously implanted mechanical valve. Intraoperatively, the left coronary artery showed an interarterial course without intramural segment or slit-like ostium. The single coronary artery was successfully preserved, and therefore no coronary revascularization was required. The postoperative course was uneventful, and she was discharged on postoperative day 12 without ischemic symptoms.

   

  Jpn. J. Cardiovasc. Surg. 55: 132-135（2026）

  Keywords：anomalous aortic origin of a coronary artery; single coronary artery; redo operation

  
  
• A Case of Type Non-A Non-B Acute Aortic Dissection with Malperfusion Syndrome Achieving Favorable Outcomes with Thoracic Endovascular Aortic Repair and Endovascular Treatment　K. Kanda et al.　136
  A Case of Type Non-A Non-B Acute Aortic Dissection with Malperfusion Syndrome Achieving Favorable Outcomes with Thoracic Endovascular Aortic Repair and Endovascular Treatment
  

  Keisuke Kanda＊	Atsumi Kosaka＊	Naotaka Motoyoshi＊

  
  

  (Department of Cardiovascular Surgery, Osaki Citizen Hospital＊, Osaki, Japan)
  

  A 54-year-old man presented with sudden back pain, weakness and coldness in both lower limbs, and was transported to our hospital by ambulance. Contrast-enhanced CT revealed an acute type non-A non-B aortic dissection, with the primary entry tear located in the aortic arch and extending to both external iliac arteries. The dissection was complicated by intestinal ischemia and bilateral lower limb ischemia due to severe true lumen narrowing. To achieve true lumen expansion and rapid reperfusion of ischemic tissue, thoracic endovascular aortic repair （TEVAR） was performed from the distal aortic arch to the descending aorta, leaving the primary entry untreated. In addition, endovascular therapy （EVT） of the superior mesenteric artery （SMA） was performed to address true lumen stenosis caused by thrombus formation in the false lumen. The acute clinical course was favorable, avoiding the need for bowel resection. Four months later, progressive enlargement of the false lumen necessitated total arch replacement with a frozen elephant trunk procedure, which resulted in a favorable postoperative outcome. This case highlights the potential of early TEVAR combined with EVT to achieve rapid organ reperfusion and improve outcomes in acute aortic dissection with malperfusion syndrome.

   

  Jpn. J. Cardiovasc. Surg. 55: 136-141（2026）

  Keywords：acute aortic dissection; malperfusion syndrome; TEVAR; EVT

  
  
• A Case of Single Coronary Artery with Stanford Type A Acute Aortic Dissection　A. Nakamura et al.　142
  A Case of Single Coronary Artery with Stanford Type A Acute Aortic Dissection
  

  Akihiro Nakamura＊	Ryohei Kobayashi＊	Koji Shimada＊

  
  

  （Department of Cardiovascular Surgery, Niigata Prefectural Shibata Hospital＊, Niigata, Japan）
  

  A 70-year-old woman presented to the emergency department with complaints of dizziness and chest and back pain. CT revealed findings of Stanford type A acute aortic dissection. The electrocardiogram showed no abnormal findings, and transthoracic echocardiography demonstrated good left ventricular function with no asynergy. During emergency surgery, intraoperative findings revealed no coronary artery ostium in the left coronary sinus, with only one large coronary artery ostium present in the right coronary sinus. This was determined to represent a single coronary artery （SCA），and ascending aortic replacement was performed while administering cardioplegic solution both selectively and retrogradely. Weaning from cardiopulmonary bypass was smooth, and the patient recovered without perioperative myocardial ischemia. Postoperative CT demonstrated an SCA originating as a single vessel from the right coronary sinus, with the right coronary artery, left anterior descending artery, and left circumflex artery arising independently. This anatomy was classified as type R-III according to the Lipton classification. Type R-III SCA is one of the rarest subtypes of SCA, and its incidental discovery during emergency surgery for acute aortic dissection is extremely uncommon. In emergency settings, preoperative diagnosis of anomalous coronary origin is difficult using routine, non-ECG-gated CT, and when such anomalies are identified intraoperatively, establishing adequate myocardial protection and avoiding coronary artery injury are crucial.

   

  Jpn. J. Cardiovasc. Surg. 55: 142-145（2026）

  Keywords：single coronary artery; anomalous coronary artery; acute aortic dissection

  
  

Progress in Cardiovascular Surgery (2025)

• Update of 2025 in Peripheral Artery Disease　H. Banno　146

U-40

• U-40 Column Report on the 2025 U-40 Regional Basic Lecture Course (BLC) Hands-on Seminars and Future Perspectives　T. Tsujimoto and Y. Koga　U1
  Report on the 2025 U-40 Regional Basic Lecture Course（BLC）Hands-on Seminars and Future Perspectives
  

  Takanori Tsujimoto＊	Yuichi Koga

  
  

  （Department of Cardiovascular Surgery, Japanese Red Cross Kobe Hospital/Hyogo Emergency Medical Center＊, Kobe, Japan）
  

  In 2025, the Basic Lecture Course（BLC）hands-on seminars hosted by U-40 were held across seven regional branches nationwide for the first time since the end of the COVID-19 pandemic. A total of 151 young cardiovascular surgeons from across the country participated in these seminars, which provided a valuable opportunity to receive direct practical instruction（Off-the-Job Training; Off-JT）from regional experts. Post-seminar surveys revealed high praise for the objective and extensive technical guidance. Furthermore, the results confirmed the seminars’ significant impact on building peer networks that transcend institutional boundaries. Based on this experience, we plan to expand participant capacity in fiscal year 2026, aiming to further enhance educational opportunities and strengthen the recruitment of young surgeons.

   

  Jpn. J. Cardiovasc. Surg. 55: U1-U3（2026）

  
  

Editor’s Post Script

• K. Kunihara