| Shinji Mizuta＊ | Satoru Sato＊ | Shintaro Nakajima＊ |
| Akira Osanai＊ | Junpei Yamamoto＊ | Masaru Sawazaki＊ |
(Department of Cardiovascular Surgery, Ichinomiyanishi Hospital＊, Ichinomiya, Japan)
An 83-year-old man under follow-up for moderate mitral regurgitation （MR） due to P2 prolapse presented with cough and dyspnea. Chest radiography revealed pulmonary congestion and right pleural effusion, suggesting acute decompensated heart failure. Despite empiric antibiotic therapy, mild inflammatory markers persisted, and infective endocarditis （IE） was suspected. Blood cultures were negative. Transesophageal echocardiography demonstrated severe MR due to a known P2 chordal rupture without definite vegetations, and brain magnetic resonance imaging showed no embolic lesions. IE was therefore considered unlikely, and the patient was diagnosed with heart failure exacerbated by new-onset atrial fibrillation. After stabilization, elective mitral valve repair with hourglass resection, concomitant Maze procedure, and left atrial appendage closure were performed. Intraoperatively, although no vegetations were observed, erythema and edema were present on the anterior leaflet and annulus along the MR jet, suggesting a localized infectious process. Valve tissue culture yielded Lacticaseibacillus paracasei, confirming IE. The patient had been consuming a commercially available probiotic drink containing L. paracasei daily for several years, suggesting gastrointestinal translocation associated with chronic probiotic intake. Six weeks of postoperative intravenous ampicillin resulted in complete recovery. Surgically confirmed cases of L. paracasei endocarditis are extremely rare. This case underscores that probiotic organisms, though generally regarded as safe, can cause IE in elderly or predisposed hosts and sometimes IE may be diagnosed from valve tissue culture in blood culture-negative cases.
Jpn. J. Cardiovasc. Surg. 55: 149-153（2026）
Keywords：Lacticaseibacillus paracasei; infective endocarditis; probiotics; culture-negative endocarditis; mitral regurgitation
| Nobuhiro Fukuda＊ | Kosuke Saku＊ | Kazuyoshi Takagi＊ |
| Hiroki Mine＊ | Tomofumi Fukuda＊ | Takanori Kono＊ |
| Takahiro Shojima＊ | Koichi Arinaga＊ | Eiki Tayama＊ |
(Division of Cardiovascular Surgery, Department of Surgery, Kurume University School of Medicine＊, Kurume, Japan)
A 72-year-old woman presented with dyspnea and was diagnosed with pericardial effusion. The patient subsequently developed severe dyspnea due to cardiac tamponade and underwent pericardiocentesis. After discharge, the patient experienced a recurrence of congestive heart failure and was referred to our hospital for further diagnosis and treatment. Echocardiography revealed constrictive pericarditis secondary to severe pericardial thickening. 18［F］Fluorodeoxyglucose （FDG） positron emission tomography-computed tomography demonstrated significant pericardial thickening with FDG uptake in the same region （SUVmax 7.12）. The patient underwent pericardiectomy, and pathological examination of the resected pericardium confirmed the diagnosis of primary malignant pericardial mesothelioma. Following discharge, the patient received chemotherapy; however, constrictive pericarditis recurred 170 days postoperatively. The patient died on postoperative day 253.
Jpn. J. Cardiovasc. Surg. 55: 154-158（2026）
Keywords：rimary malignant pericardial mesothelioma; constrictive pericarditis; cardiac tamponade; asbestos; 18［F］FDG-PET/CT
| Mikito Inouchi＊ | Michihiro Nasu＊ | Jin Tanaka＊ |
| Tateo Nakai＊ | Tomoya Takigawa＊ | |
(Department of Thoracic and Cardiovascular Surgery, Toyooka Hospital＊, Toyooka, Japan)
Case 1: 61-year-old male, after admission for multiple cerebral infarctions, was diagnosed as subacute lateral myocardial infarction with thinning of the wall and a small amount of intracardiac mural thrombus. The patient was discharged on the 33rd day after admission. However, he was urgently hospitalized for acute heart failure with pulmonary edema eight days after discharge. Echocardiography and 3D CT revealed a large left ventricular pseudoaneurysm of 628 ml from the left ventricular lateral wall to the apex, with a 3.5 cm communicating channel to the left ventricle. Emergency surgery was performed to prevent rupture and improve the pump function. The wall of the pseudoaneurysm was composed of an epicardial membrane that was tightly adhered to the pericardial membrane. No intracardiac thrombi were observed. The communicating channel was 2.5×5.0 cm. Patch closure was performed. He was discharged on postoperative day 28. Three years after surgery, his cardiac function was well maintained. Case 2: An 86-year-old man with chronic atrial fibrillation and functional mitral regurgitation was treated by a cardiologist at our hospital, but he was hospitalized repeatedly. He underwent mitral annuloplasty, tricuspid annuloplasty, and cleft closure. An echocardiogram before discharge revealed a 1.4×2.0 cm left ventricular pseudoaneurysm between the anterior papillary muscle and the mitral ring. 3D CT revealed a small left ventricular pseudoaneurysm with a small neck. Involuntary contact with the suction tube may have caused intraoperative myocardial injury. However, owing to his advanced age and small communicating channel, the patient was maintained under observation. Three years after discharge, the pseudoaneurysmal cavity was completely thrombosed, and the patient was doing well. The operative indication for left ventricular pseudoaneurysm should be decided according to the clinical symptoms, pseudoaneurysm shape, and size of the communicating channel.
Jpn. J. Cardiovasc. Surg. 55: 159-163（2026）
Keywords：ventricular pseudoaneurysm; myocardial infarction; mitral valve repair; operative indication
| Hiroyuki Seo＊ | Hidekazu Hirai＊ | Tadahiro Murakami＊ |
| Daisuke Kaku＊ | ||
(Department of Cardiovascular Surgery, Osaka Saiseikai Noe Hospital＊, Osaka, Japan)
Left ventricular outflow tract pseudoaneurysms （LVOTPs） are a rare but life-threatening entity. We report a case of LVOTP which was incidentally identified during aortic valve replacement, and required reoperation because of an intracardiac fistula. A 70-year-old woman, with a history of prolonged hospitalization with long-term antibiotic therapy due to persistent unknown fever and dyspnea 1 year previously, presented to hospital with exertional dyspnea. Transthoracic echocardiography showed severe aortic valve stenosis and regurgitation, for which surgical intervention was planned. Intraoperatively, a 12-mm slit-like defect was observed in the non-coronary cusp annular region of the aortic valve, from which a pseudoaneurysm extended into the left ventricular outflow tract. A diagnosis of an unrecognized LVOTP, which had not been identified preoperatively, was made. The orifice of the pseudoaneurysm was closed using a bovine pericardial patch, followed by aortic valve replacement. The postoperative course was uneventful. However, postoperative contrast-enhanced computed tomography showed persistent contrast filling into a 15-mm LVOTP. Further evaluation demonstrated a separate 2-mm residual communication with the pseudoaneurysm located in the subaortic left ventricular outflow tract, which was distinct from the initial repaired orifice of the pseudoaneurysm. Therefore, the patient underwent a reoperation. The bioprosthetic valve was removed, and the residual communication in the left ventricular outflow tract was closed using a bovine pericardial patch, followed by re-replacement of the aortic valve. The postoperative course after the second operation was favorable, and she was discharged on postoperative day 14. Postoperative contrast-enhanced computed tomography （CT） showed the complete disappearance of contrast leakage into the LVOTP. At a 3-year follow-up, the patient was alive and well, and CT showed remission of the LVOTP and no evidence of recurrence. We believe that the LVOTP in the present case was caused by occult infective endocarditis with an annular abscess and intracardiac fistula 1 year previously.
Jpn. J. Cardiovasc. Surg. 55: 164-169（2026）
Keywords：left ventricular outflow tract; pseudoaneurysm; intracardiac fistula; infective endocarditis; pericardial patch closure
| Tomoyuki Matsuba＊ | Yuki Ogata＊ | Hideyuki Satozono＊ |
| Hiroto Yasumura＊ | Koichiro Shimoishi＊ | Yoshihiro Fukumoto＊ |
| Goichi Yotsumoto＊ | Yoshiharu Soga＊＊ |
(Department of Cardiovascular Surgery, Kagoshima City Hospital＊, Kagoshima, Japan, and Department of Cardiovascular Surgery, Graduate School of Medical and Dental Sciences, and Kagoshima University＊＊, Kagoshima, Japan)
We report a rare case of dynamic left ventricular outflow tract obstruction （LVOTO）, with systolic anterior motion （SAM） during a Cone operation for Ebstein’s anomaly in an adult patient. A Japanese woman in her 40 s diagnosed with Ebstein’s anomaly in her childhood of complained with progressively worsening exertional dyspnea over several years. She was referred to our hospital for surgery. A Cone operation was performed via median sternotomy and on cardiopulmonary bypass （CPB）. During weaning from CPB, SAM developed severe mitral valve regurgitation （MR） and LVOTO. Because the left atrial pressure was low （3-5 mmHg）, and the central venous pressure was high （more than 20 mmHg）, the condition was attributed to right heart failure. Weaning from CPB was demanding, and an additional bidirectional Glenn procedure was performed and catecholamines were reduced to improve the SAM. Intra-aortic ballon pumping （IABP） was introduced to unload left ventricular afterload. Weaning from CPB was tried again; however, the severe MR and LVOTO was not improved and she was therefore returned to the ICU on central V-A extracorporeal membrane oxygenation （ECMO） and IABP. The next day, transesophageal echocardiography confirmed that the IABP adversely affected the SAM and LVOTO. Noradrenaline and vasopressin were administered to augment afterload, and the IABP support was reduced, which improved the MR and LVOTO, and allowed weaning from the ECMO on the same day. On the third postoperative day, the removal of the ECMO cannulas and IABP catheter and the delayed sternal closure were performed.
Jpn. J. Cardiovasc. Surg. 55: 170-175（2026）
Keywords：Ebstein’s anomaly in an adult; Cone operation; systolic anterior motion; dynamic left ventricular outflow tract obstruction
| Yuki Sawai＊ | Yoshiyuki Kobayashi＊ | Minori Tateishi＊ |
| Tomoyuki Minami＊ | Kaori Mori＊ | Kiyotaka Suzuki＊ |
| Makoto Mo＊ | Aya Saito＊ |
(Department of Surgery, Yokohama City University Hospital＊, Yokohama, Japan, Department of Cardiovascular Surgery, Yokohama Minami Kyosai Hospital＊＊, Yokohama, Japan, and Namiki Clinic＊＊＊, Yokohama, Japan)
In this study, we report two challenging cases of primary pulmonary artery （PA） sarcoma, in which we struggled to make an appropriate diagnosis for timely treatment. In case 1, a 27-year-old man presented with dyspnea. Contrast-enhanced computed tomography （CT） revealed a large filling defect, predominantly in the right PA, extending into the left PA. The patient was diagnosed with pulmonary embolism, and was administered anticoagulant therapy. Despite therapy, the mass showed rapid growth with near-total occlusion of the right PA. Positron emission tomography/computed tomography revealed a highly suspicious isolated PA sarcoma. The patient underwent en-bloc resection of the tumor and right total pneumectomy. Left lung metastasis was confirmed two months later, and the patient received chemotherapy. Case 2 was a 47-year-old man who presented with exertional breathlessness. Plain CT showed an infiltrative shadow in the left upper lung field, suggestive of pneumonia, and he received antibiotic therapy without any improvement. Contrast-enhanced CT suggested PA sarcoma, and surgical resection was planned. Preoperative follow-up CT showed rapid progression and distant metastasis of the tumor; thus, surgical resection was withdrawn, and he received chemotherapy instead. In both cases, there was a substantial delay between symptom onset and diagnosis, rendering curative surgery unfeasible. To achieve longer overall survival in primary PA sarcoma, it is essential to identify this disease as a differential diagnosis for PA mass lesions at the first site in order to achieve surgical resection, including the main tumor and metastatic lesions.
Jpn. J. Cardiovasc. Surg. 55: 176-179（2026）
Keywords：primary pulmonary artery sarcoma; pulmonary thromboembolism
| Daisuke Heima＊ | Etsuro Suenaga＊ | |
(Department of Cardiovascular Surgery, Kansai Electric Power Hospital＊, Osaka, Japan)
A 61-year-old man with a history of paroxysmal atrial fibrillation presented with a two-year history of exertional dyspnea that had progressively worsened, accompanied by an increased frequency of atrial fibrillation episodes. During these episodes, he developed aggravated dyspnea and presyncope and was referred to our institution for further examination and treatment. Further examination revealed a superior-type atrial septal defect, severe tricuspid regurgitation with posterior leaflet prolapse, and mild mitral regurgitation. The patient underwent atrial septal defect closure, tricuspid valve repair, mitral valve repair, and concomitant surgical ablation （Maze procedure）. Intraoperative findings demonstrated that tricuspid regurgitation resulted from a combination of primary leaflet pathology and annular dilation related to chronic volume overload. Tricuspid valve repair was therefore performed using semi-rigid ring annuloplasty combined with edge-to-edge repair for a residual leaflet cleft, and artificial chordal reconstruction to achieve adequate leaflet coaptation. The postoperative course was uneventful, and postoperative echocardiography showed no residual tricuspid regurgitation. This case demonstrates that favorable outcomes can be achieved by combining surgical techniques that address the underlying mechanisms of tricuspid regurgitation, including both a primary etiology （chordal rupture） and a secondary etiology （volume overload associated with atrial septal defect）.
Jpn. J. Cardiovasc. Surg. 55: 180-184（2026）
Keywords：artificial chordae tendineae; ruptured chordae tendineae; primary tricuspid regurgitation; atrial septal defect
| Norimasa Haijima＊ | Satoru Murata＊ | Mikihiko Kudo＊ |
(Department of Cardiovascular Surgery, National Hospital Organization Saitama Hospital＊, Wako, Japan)
In patients with an aortic arch aneurysm, the coexistence of porcelain aorta and shaggy aorta markedly limits the use of thoracic endovascular aortic repair （TEVAR）, because calcified landing zones increase the risk of endoleak and friable atheroma increases the risk of cerebral embolism. In such ultra-high-risk situations, open total arch replacement that minimizes aortic manipulation and allows secure cerebral protection becomes a reasonable alternative. A 78-year-old man presented with persistent chest and back pain suggestive of impending rupture. Contrast-enhanced computed tomography showed a 58-mm aortic arch aneurysm with a penetrating atherosclerotic ulcer （PAU） and surrounding hematoma. The ascending aorta had only a 3-cm disease-free proximal segment, whereas the remaining ascending and arch segments showed circumferential calcification and diffuse atheromatous change compatible with porcelain and shaggy aorta. Because of the high embolic risk and the inadequate, calcified landing zone, TEVAR was considered inappropriate. Total arch replacement was performed using the frozen elephant trunk （FET） technique under brain isolation （BIT）. The right and left axillary arteries and the left common carotid artery were exposed and used as three inflow routes to maintain antegrade cerebral perfusion during cooling and circulatory arrest. A guidewire that had been advanced from the femoral artery to the ascending aorta was employed in a pull-through manner to deploy the FET slowly in a blood-filled field at zone 0, with the intention of avoiding scraping of the aortic wall. Arch reconstruction was then completed with a two-branched graft. Circulatory arrest time was 59 min, and cardiopulmonary bypass time was 157 min. Recovery was uneventful. The patient was extubated 5 h after surgery, left the intensive care unit on postoperative day 3, and was discharged home on day 14. Postoperative computed tomography confirmed appropriate positioning of the FET without endoleak or embolic complications. Even when porcelain and shaggy aorta make TEVAR unsuitable, open total arch replacement that combines brain isolation with guidewire-assisted, blood-filled deployment of an FET can achieve safe arch reconstruction while keeping embolic risk to a minimum.
Jpn. J. Cardiovasc. Surg. 55: 185-189（2026）
Keywords：porcelain aorta; shaggy aorta; frozen elephant trunk; total arch replacement; cerebral protection
| Kenichiro Suno＊ | Yasuhiro Kamikubo＊ | |
（Department of Cardiovascular Surgery, Kushiro City General Hospital＊, Kushiro, Japan）
A 78-year-old woman underwent aortic valve replacement and ascending aortic replacement for severe aortic stenosis associated with a bicuspid aortic valve and ascending aortic dilatation. Seven months after surgery, delayed healing of the median sternotomy wound with persistent serous discharge developed. Despite repeated local treatments, including sternal wire removal, negative pressure wound therapy, bone debridement, and pectoralis major muscle flap reconstruction, the wound failed to heal. Wound and blood cultures were negative, and computed tomography revealed fluid collection surrounding the prosthetic graft, suggesting perigraft seroma. Redo graft replacement was considered highly invasive, and omental flap transposition was not feasible because of a prior gastrectomy. Therefore, relining thoracic endovascular aortic repair （TEVAR） of the ascending aorta was performed using an Excluder cuff. After the procedure, wound exudation decreased, enabling outpatient management.
Jpn. J. Cardiovasc. Surg. 55: 190-193（2026）
Keywords：perigraft seroma; ascending aortic replacement; TEVAR
| Nobuko Yamamoto＊ | Hiroyoshi Komai＊ | Yuka Kitaoka＊ |
| Masato Ohno＊ | Noriyuki Miyama＊ | Noriyasu Morikage＊＊ |
| Tadaaki Koyama＊＊ |
(Department of Vascular Surgery, Kansai Medical University Medical Center＊, Moriguchi, Japan, and Department of Cardiovascular Surgery, Kansai Medical University＊＊, Hirakata, Japan)
We experienced three surgical cases for true deep femoral artery （DFA） aneurysm. Case 1 was treated with a prosthetic graft replacement for the DFA aneurysm （maximum transverse diameter 31 mm）. This case was also complicated by a small abdominal aortic aneurysm. At 2 years and 6 months after surgery, the graft was occluded and there were no ischemic symptoms. Case 2 presented with swelling in the thigh that was revealed to be a DFA aneurysm （maximum transverse diameter 31 mm） and bilateral popliteal artery aneurysms. A small abdominal aortic aneurysm was also present. A prosthetic graft replacement for the DFA aneurysm was placed during surgery performed to bypass the ipsilateral popliteal aneurysm. The patient had a postoperative myocardial infarction due to intraoperative bleeding, but has since recovered well. Case 3 was a DFA aneurysm （maximum transverse diameter 49 mm） and bilateral popliteal artery aneurysm that was diagnosed incidentally in a very elderly patient. Peripheral coil embolization and suture closure of the orifice were performed for the DFA aneurysm, and bypass was performed for the popliteal artery aneurysm. However, blood flow into the DFA aneurysm remained after surgery, and despite ligation of the inflow artery and coil embolization, the aneurysm showed a tendency to enlarge, so the suture closure was undergone 2 years and 9 months after the initial surgery. In our department, we perform revascularization of DFA aneurysms in scheduled surgery as the first-line treatment, considering that the DFA is an important collateral source in the future progression of lower limb atherosclerosis.
Jpn. J. Cardiovasc. Surg. 55: 194-198（2026）
Keywords：deep femoral artery aneurysm; peripheral arterial aneurysm; revascularization