The patient was a 59-year-old man who had undergone aortic valve replacement with a mechanical valve for aortic stenosis eight years ago. Six months ago, he developed complete atrioventricular block and underwent pacemaker implantation. One day before admission, he presented to a local clinic with complaints of dyspnea and chest pain. Suspecting acute myocardial infarction, he was referred to our hospital for further evaluation and was subsequently admitted. On admission, he exhibited fever and elevated inflammatory markers. Transthoracic echocardiography and computed tomography revealed vegetations on the prosthetic valve and an annular abscess with aneurysmal dilatation of the sinus of Valsalva. Based on these findings, prosthetic valve endocarditis was diagnosed, and semi-urgent surgery was performed. Intraoperatively, numerous vegetations were found attached to the prosthetic valve annulus, and the annular abscess had extensively invaded the myocardium circumferentially. Aneurysmal dilatation of the sinus of Valsalva was observed, especially around the left and right commissures. After debridement of the abscess cavity, it was determined that Bentall procedure was not feasible due to extensive annular destruction and fragility of the surrounding myocardial tissue. Therefore, we opted for a root reconstruction using the “graft insertion technique” as described by Nakamura et al. A 5-cm length of tube graft was inverted and inserted from the aortic root into the left ventricular outflow tract (LVOT). Nine mattress sutures using 3-0 polypropylene with pledgets were placed from inside the graft through the LVOT, with external reinforcement using a Teflon felt strip, followed by continuous suturing for added security. The intraventricular portion of the graft was pulled out through the LVOT and trimmed. A preconstructed composite graft was then anastomosed to the trimmed end. The right coronary artery was reimplanted using the button technique. The left coronary artery was injured during dissection of adhesion and could not be reimplanted; therefore, a bypass from the great saphenous vein to the left anterior descending artery was performed. Despite the loss of healthy annular tissue due to complete debridement of the infected valve and myocardial abscess, the reconstruction of the aortic root was successful without the need for additional hemostatic sutures. The “graft insertion technique，” though not yet widely established, offers a valuable approach for reconstructing severely damaged and fragile aortic roots in the setting of prosthetic valve endocarditis. It allows for safe and reliable surgical repair even in challenging anatomical conditions.

The system of the Japanese Board of Cardiovascular Surgery is changing. Since the last time, we have deliberated on the medical specialty board for U-40 column articles about the problems faced by young cardiovascular surgeons. This time, we conducted the second survey to U-40 members about the realities of becoming a board-certified cardiovascular surgeon. The results showed the circumstances and details on how to acquire the board certification. Moreover, we discussed about the current problems and future perspectives for the young cardiovascular surgeons.

We report a case of ruptured chronic type B aortic dissecting aneurysm that was successfully treated with the Candy plug technique to exclude a false lumen. A 57-year-old man had undergone abdominal fenestration for complicated acute type B aortic dissection previously. He then underwent debranching TEVAR for an impending rupture because of a dilated thoracic aortic dissecting aneurysm in 2014. After one year, the aneurysm was ruptured because of continuous distal flow of the false lumen. We performed TEVAR using the Candy plug technique, and he was discharged on the 11th postoperative day. The false lumen diameter was reduced. TEVAR using the Candy plug technique for chronic type B aortic dissection was thought to be useful in high-risk patients, but we need more careful observation.

The efficacy of minimally invasive cardiac surgery (MICS) has often been reported. However, in Japan most of these procedures are supported with robotic systems, which are expensive. We report the technique of atrial septum defect (ASD) closure by MICS and a three-dimensional endoscope without the aid of a robotic system. From March 2012 to April 2015, we performed ASD closure using this method in 7 patients. The use of a three-dimensional endoscope enables cardiac surgery to be performed through smaller incisions (≤5 cm in width). We have adopted this method of ASD closure with the Maze procedure for patients complicated by atrial fibrillation. The operation time will decrease as we improve our surgical technique. Our current practice is to attempt ASD closure with totally endoscopic support.

Aortopulmonary fistula with an arch aortic aneurysm is a rare disease that is difficult to diagnose and often presents with sudden, life-threatening heart failure. Here we report a case of aortopulmonary fistula for which we performed a thoracic endovascular aortic repair (TEVAR) with favorable results. A 79-year-old man presented with slurring of speech and body malaise at a neighborhood clinic. A distal arch aortic aneurysm was detected on chest computed tomography (CT) scans, and the patient was referred to our hospital for further management. We identified a saccular aneurysm and the dilated pulmonary artery, with maximum vessel diameters of 80 and 38 mm, respectively, on preoperative chest CT scans. He was diagnosed with an impending aortic rupture and a TEVAR was performed after preparing for a cervical ramification bypass. Intraoperatively, the aortopulmonary fistula had invaded the pulmonary artery, and the shunt created by the invasion was responsible for the sudden exacerbation of heart failure symptoms in the patient. The diameter of the saccular lump did not increase in the postoperative CT and follow-up visits were scheduled for subsequent monitoring. In the absence of significant complications and with improvement of heart failure symptoms, the patient was discharged from our hospital on the 37th postoperative day. He was later transferred to a neighborhood clinic for rehabilitation and subsequently discharged for further recuperation at home in the fifth postoperative month.

Syphilitic aortic aneurysm became rare after the discovery of penicillin. Syphilitic aortitis involves the ascending aorta and dilates the aortic annulus, causing aortic valve regurgitation. We report a case of syphilitic aortic aneurysm with severe aortic valve regurgitation, which was successfully treated with the replacement of the valve-sparing root and the total arch. A 55-year-old man, admitted earlier to another hospital for colon diverticulum, was found to have an aortic arch aneurysm. Enhanced computed tomography revealed the aneurysm of the ascending aorta to the transverse arch aorta with the maximum short diameter of the aneurysm at 68 mm. He also had a saccular aneurysm in the ascending aorta. Although he had never had a history of syphilis, a routine laboratory test for syphilis was positive. That said, we looked upon this case as a syphilitic aortic aneurysm. In preoperative cardiac echography, the aortic regurgitation was severe with mild valve stenosis and mainly due to dilation of the aortic root. We thought the native valve could be spared and replaced both the valve-sparing root and the total arch. He was discharged on the 11th postoperative day without any complications.