Objective: The control of myocardial temperature is very important in myocardial protection methods. We investigated the validity of myocardial protection methods at our institution using noninvasive thermography as a means of determining the effectiveness of myocardial protection, with the aim of confirming that myocardial protection solution is correctly infused. Methods: Of 52 extracorporeal circulation cases with cardiac arrest from May 2020 to June 2022, 10 cases with cardiac arrest by progressive myocardial protection with Microplegia, a blood myocardial protection, were included. Infusion was performed at an infusion temperature of 20℃, with an intracircuit pressure of less than 300 mmHg and a flow rate of 250-350 ml/min maintained in a progressive manner. Myocardial temperature in the anterior region of the heart was measured using a thermographic camera at a distance of 80 cm from the heart. Results: The cardiac surface temperature before the start of myocardial protection was 32.5±1.0℃. After the start of infusion, the cardiac surface temperature at the time cardiac arrest was obtained was 27.4±1.3℃. In all cases, the cardiac surface temperature at the time of cardiac arrest was visually heterogeneous. Further infusion was continued, and the average time to reach the lowest visually uniform surface temperature was 342±23 s. The mean cardiac surface temperature at the end of myocardial protection was 22.4±1.3℃. At the start of myocardial protection solution infusion, the myocardial surface cooled faster in muscle than in visible fat, in the order aorta>myocardium from the apex>cardiac base. The postoperative course was generally good in all cases with respect to EF, CKMB, catecholamine use, extubation time, postoperartive hospital stay, and outcomes. Conclusion: It was found that a time of about 360 s is needed to uniformly cool the myocardial temperature during infusion of myocardial protection solution. Furthermore, by confirming the cooling of the base of the heart, it is suggested that it is inferred that the whole is cooled. To avoid problems caused by inadequate myocardial protection, it is suggested that measuring myocardial temperature using a non-invasive, simple thermal imaging camera can assist in determining the effectiveness of myocardial protection, and is expected to establish the safety of further myocardial protection.

Sarcomas with BCOR genetic alternations, formerly treated as Ewing-like sarcomas, are malignant tumors with a poor prognosis. They have been classified under the category of undifferentiated small round cell sarcomas of bone and soft tissue since 2020. There are only a few reports on surgical treatment for these sarcomas, as they are extremely rare, and no specific treatment has been established. Among them, there have been no reports on the treatment of patients with intracardiac invasion. We report herein the case of intracardiac invasion of a rare sarcomas with BCOR genetic alternations. The patient is a 14-year-old girl who presented to the hospital with a chief complaint of left upper arm pain. Computed tomography (CT) showed tumors in the left axilla and left thoracic cavity, and after biopsies of each, we diagnosed the patient with sarcomas with BCOR genetic alternations. Although chemotherapy was planned, echocardiography revealed a mobile tumor in the left atrium, we decided to perform surgical procedure before chemotherapy to reduce the risk of embolism and sudden death. The tumor invaded directly the left upper pulmonary vein and extended into the left atrium. Since right lung metastasis was suspected, we considered the en bloc tumor resection while preserving the left lung. However it was difficult because the tumor invaded into the vicinity of the lower lobe bronchus. Concerned about extracardiac seeding, we resected the tumor as much as possible intravascularly. Although there was residual tumor, chemotherapy was started immediately after surgery, and the tumor has shrunk in size. We are planning to remove the entire tumor after several courses of chemotherapy.

A 47-year-old man had severe mitral regurgitation after severe skin eruption, so mitral valve replacement was electively performed 8 months later. A median sternal wound opened spontaneously and had purulent exudate on the 5th postoperative day (5 POD). We had suspicion of bacterial mediastinitis, so we drained the anterior mediastinum and tried antibiotic treatment. However, the microbiological stains and culture were negative, and adipose tissue was extremely melted with pustules around the wound. Considering other diseases without infection, we consulted to a dermatologist and tried highdose steroid therapy as pyoderma gangrenosum (PG) appeared on the 8 POD. Meanwhile, the sternum was left open and apllied a negative pressure dressing applied with Negative Pressure Wound Therapy (NPWT). The wound responded remarkably to steroid therapy, so we closed the sternum on the 10 POD, and sutured the sternal wound on the 19 POD. We tapered off steroids after the suture. PG can be caused by the trauma of surgery, so we have to make a decision on whether to use high dose steroid therapy in the postoperative period. We report this case as one of the differential diseases that the surgeons must know.

The patient was an 89-year-old male who underwent transcatheter edge-to-edge repair to the mitral valve using MitraClip for severe degenerative mitral regurgitation (MR) one year earlier. Although two clips were implanted, grade III/IV MR still remained. As his heart failure progressed, he was referred to us for surgery. The patient also had aortic stenosis. He underwent mitral valve repair and aortic valve replacement. The postoperative course was uneventful. He was transferred to the referring hospital on postoperative day 14. When performing MitraClip for degenerative MR, it is important to consider carefully not only the operative risk for open surgery but also the anatomical adequacy of MitraClip. When MitraClip fails to control MR, early surgical intervention should be considered.

An 83-year-old woman (BSA 1.36 m²) who had undergone aortic valve replacement (Magna ease 19 mm), mitral valve replacement (Epic mitral 25 mm), tricuspid annuloplasty (De Vega technique), and pulmonary vein isolation eight years earlier was referred to our hospital due to her heart failure symptoms. Ultrasound cardiography revealed severe mitral regurgitation due to perforation of bioprosthetic valve, severe mitral valve stenosis (mean pressure gradient 7.8 mmHg) due to bioprosthetic deterioration, and subsequent pulmonary hypertension (mean pulmonary artery pressure 49 mmHg, tricuspid regurgitation pressure gradient 85.5 mmHg). We performed a redo aortic valve (Inspiris 23 mm) and mitral valve (Epic mitral 29 mm) replacement using the Manouguian technique. The postoperative course was uneventful and pulmonary hypertension improved (tricuspid regurgitation pressure gradient 39.6 mmHg).

Tricuspid annulus has an asymmetric three-dimensional structure with the posteroseptalportion lowest toward the apex from the right atrium and the anteroseptal portion the highest. The tricuspid annulus of a patient with situs inversus has a mirror image of a patient with situs solitus, and the posteroseptal and the anteroseptal portion remains the lowest and the highest toward the apex, respectively, as the situs solitus. Therefore, we assumed that the posteroseptal portion would become higher and the anteroseptal portion would become lower using a conventional three-dimensional rigid ring turned over for tricuspid regurgitation in the situs inversus, and the coaptation of the three leaflets would be poor. In this case, we performed tricuspid annuloplasty using a tricuspid flexible band, mitral valve plasty, left atrial plication, left atrial appendage closure for a situs inversus dextrocardia patient with tricuspid regurgitation, mitral regurgitation, and chronic atrial fibrillation.

Cardiac metastasis from cervical cancer is rare. We herein present a case involving a 54-year-old woman with cervical cancer who was undergoing radiotherapy for left supraclavicular lymph node metastasis. The patient was admitted to the hospital because of shortness of breath. Transthoracic echocardiography showed a large mass in the right ventricle. To rescue the patient from circulatory collapse, we surgically resected the intracardiac mass via a right ventricular incision parallel to the posterior descending artery and left anterior descending artery. This approach prevented right ventricular outflow tract obstruction and perioperative pulmonary embolization, which could have led to death. The intracardiac mass was diagnosed as squamous cell carcinoma. After hospital discharge, the patient underwent chemotherapy. An echocardiography performed 3 months postoperatively showed recurrence of the cardiac metastasis, and the patient died 5 months later. Cardiac metastasis in the right ventricle can present as pulmonary embolization. Although rare, most cases of metastasis from cervical carcinoma to the heart have an extremely poor prognosis.

Retrograde myocardial protection plays an important role in cardiac surgery and is widely used. We herein report a rare cardiac surgical case complicated with small coronary sinus ostium in which the cannula of retrograde cardioplegia could not be inserted. A 58 years old man was referred for the treatment of regurgitation and aortic regurgitation. Preoperative ECG gated computed tomography (CT) showed that the orifice of the largest coronary sinus was located in the right atrium with a diameter of only 4 mm with an other 3 smaller orifice in the right atrium and ventricle, which appeared to make it difficult to perform retrograde myocardial protection. The operative finding was consistent with the preoperative CT finding and mitral valve repair and aortic valve replacement were performed using only selective antegrade myocardial protection. We should bear in mind that small coronary ostium exists and preoperative assessment of the size of coronary sinus might be important.

Giant coronary artery aneurysms are relatively rare and are usually associated with Kawasaki disease, atherosclerosis, congenital disease, or trauma. Although a coronary-pulmonary artery fistula is a known complication, clear guidelines for treatment of this condition remain unavailable. We report a case of multiple giant coronary artery aneurysms associated with a coronary-pulmonary artery fistula in a patient who underwent fistulotomy, aneurysmectomy, and coronary artery bypass graft surgery. A 66-year-old woman was initially evaluated by her primary care physician following right breast cancer surgery. She denied any specific symptoms; however, she was referred to our hospital for evaluation of an abnormal shadow detected on chest radiography. Contrast-enhanced computed tomography (CT) performed at our hospital revealed multiple giant coronary artery aneurysms(approximately 45 mm in size), as well as right and left coronary-pulmonary artery fistulas. We performed simultaneous aneurysmectomy, fistula resection, and coronary artery bypass grafting for management of the giant coronary artery aneurysms concomitant with coronary-pulmonary artery fistulas. Threedimensional CT was useful for accurate imaging of the location of the coronary artery aneurysms, fistula vessels, and the left anterior descending, and left circumflex arteries. It is essential to accurately delineate the boundary between the aneurysms and healthy coronary arteries and fistula vessels, and coronary artery bypass graft surgery should be performed if necessary. We report a rare case of the aforementioned clinical condition, together with a literature review.

A 48-year-old man was treated for heart failure at a nearby hospital, and echocardiography revealed thrombi in both ventricles. He was referred to our hospital for a detailed examination and treatment. Coronary angiography was performed, and the results were #2-3 50%, #5 50%, #6 100%, and #11 75%. Echocardiography revealed diffuse hypokinesis with an ejection fraction (EF) of 31%, which was indicative of old myocardial infarction. The left intraventricular thrombus was floating and adherent to the apex of the heart, and we judged that immediate surgical intervention was necessary to remove the thrombus and perform coronary artery bypass grafting. The right ventricular thrombus was removed through the tricuspid valve with an incision in the right atrium using a rigid endoscope to ensure that no thrombus remained behind. There were no perioperative embolic complications, and oral administration of direct oral anticoagulants (DOAC) was continued for one year after the operation. However, no recurrence of thrombosis was observed, and the prognosis was good.

A 35-year-old man was followed up for systemic lupus erythematous with antiphospholipid antibody-positive. He underwent an echocardiogram for a closer examination of his heart murmur. Transthoracic echocardiography revealed a calcified mass of 30 mm in diameter in the right ventricular outflow tract. Surgery was performed through an upper hemi-sternotomy. After establishment of beating-heart cardiopulmonary bypass, the pulmonary trunk was opened with a longitudinal incision. The highly calcified mass was located immediately below the pulmonary valve. We exfoliated the mass from the right ventricle, and resected it en bloc during short-term cardiac arrest. The postoperative pathological diagnosis was a calcified amorphous tumor. The patient was discharged from our hospital on postoperative day 12．No tumor recurrence was observed 9 months after the surgery.

A 72-year-old man presented with a thoracoabdominal aortic aneurysm which had been diagnosed six years earlier. Surgical intervention was planned due to aortic diameter enlargement up to 57 mm and back pain. Although he had a shaggy aorta, a preoperative work-up revealed pulmonary dysfunction, which made open repair via thoracotomy challenging. Therefore, a decision was made to proceed with two-stage thoracic endovascular aortic repair (TEVAR) with debranching and functional brain isolation. In the first operation, iliofemoral bypass with debranching of four abdominal vessels was performed via median laparotomy to secure the access route and distal landing zone. In the second operation, two debranching TEVAR was performed. The functional brain isolation technique was employed using cardiopulmonary bypass and balloon occlusion of the left subclavian artery to prevent an embolic stroke from the shaggy aorta during the stent graft deployment. In addition, embolic protection of abdominal branches and lower extremities was established using a balloon occlusion and a sheath in the iliac arteries. The postoperative course was uneventful with no embolic complications. Although the shaggy aorta is not evaluated in Japan SCORE or Euro SCORE, it is a risk factor for perioperative stroke. Those patients would benefit from a tailored approach to prevent embolic complications.

The patient is a 55-year-old woman. Enhanced contrast computed tomography (CT) was conducted to comprehensively assess the renal deformity, revealing a severe stenosis in proximity to the celiac artery (CA) and the point of origin of the superior mesenteric artery (SMA), as well as dilatation of the inferior mesenteric artery (IMA), an aneurysm of the left colic artery (LCAA), and a limbal aneurysm of the splenic flexure arcades. To address the LCAA, coil embolization was performed, and a two-stage bypass of the SMA was carried out to enhance blood flow to the visceral arteries, leading to IMA dilation amelioration.

We report a case of surgery for an infectious left subclavian artery aneurysm in a patient with metal allergy. The patient was a 41-year-old man allergic to iron, silver, manganese, and chromium. He had received a Nitinol stent in the left subclavian artery at a previous hospital. One stent had fallen out during implantation, and was put away in the terminal aorta. Ten days after the left subclavian implantation, the patient developed left shoulder pain and fever, which continued for 2 weeks. Contrastenhanced CT scan revealed a pseudoaneurysm of the left subclavian artery and abdominal aortitis. The patient underwent left subclavian artery aneurysmectomy, aorto-left subclavian artery bypass using the great saphenous vein, and removal of the stents in the left subclavian artery and abdominal aorta. The surgery was performed through a median sternotomy with cardiopulmonary support. A contrast-enhanced CT scan taken on the 12th postoperative day revealed a pseudoaneurysm of the abdominal aorta, and the patient underwent abdominal aortic artery replacement surgery on the 14th postoperative day. The patient was discharged from the hospital on the 27th day after the first surgery. The treatment of an aneurysm should be selected according to the patient’s background as well as anatomical factors.

There are no clear guidelines on thromboprophylaxis in patients following Fontan surgery. In addition, most reports on thromboprophylaxis refer to systemic thromboembolism. Therefore, there are few reports on thromboprophylaxis for extracardiac conduits. We experienced a case of thrombus in extracardiac conduit leading to liver damage after the Fontan completion. The patient was an 11-year-old girl, who underwent the Fontan procedure at 3 years of age. She was on aspirin for thromboprophylaxis. Eight years postoperatively, cardiac catheterization demonstrated severe conduit stenosis, and chronic liver damage was seen at that time. The patient successfully underwent conduit replacement. Subsequently, ascites disappeared and platelet count improved. Conduit stenosis after Fontan completion is a rare but serious complication, therefore we should always keep it in mind and aspire to early detection.

Minimally invasive cardiac surgery (MICS: Minimally Invasive Cardiac Surgery) through a minithoracotomy is becoming a standard approach for heart valve surgery. According to JCVSD data for 2018-2019, 42.6% of mitral valve surgeries were performed using the MICS approach. MICS has various advantages over the standard sternotomy approach, such as superior cosmesis, faster recovery and avoidance of sternal complications. However, caution cannot be overemphasized as procedure-related complications are yet to be fully addressed. These complications include chest wall bleeding, unilateral pulmonary edema, vascular injury, and leg ischemia. Some of these complications tend to occur more frequently during the learning curve period. A strict collaboration between surgeons, anesthesiologists, and operating staff is critical for avoid these complications.

Mechanical Circulatory Support (MCS) is established to salvage cases with cardiogenic shock. MCS includes intra-aortic balloon pumping (IABP), veno-arterial extracorporeal membrane oxygenation (VA-ECMO), or pump-catheter. Prompt introduction of these devices enables 1) unloading of left and/or right ventricles, 2) sufficient supply of oxygenated blood to end-organs, and 3) maintenance of pulmonary circulation. Under MCS, then, cause of cardiogenic shock is explored and appropriate treatments are given to wean-off the MCS. In this review, selection of the MCS devices, technical tips of each MCS, and management of the cases under MCS are explained.

The first examination of the new board of the Japanese cardiovascular surgery took place in 2022. As it is a transitional period for the new system, many doctors are not familiar with the changes and details of the new system, and some have their concerns. Here, we held a round-table discussion with doctors who actually took the new board of the Japanese cardiovascular surgery under the new system, and we summarized their opinion.