Objectives: Distal stent graft-induced new entry (dSINE), defined as a new tear caused by a stent graft, has been increasingly observed following total arch replacement using frozen elephant trunk (FET) for aortic dissection. We aimed to investigate the incidence and treatment of dSINE after the use of FET. Methods: This retrospective study evaluated 70 patients who underwent total arch replacement using FET for aortic dissection between August 2014 and March 2020. They were followed up for at least 6 months postoperatively. Between-group comparisons were performed between those who did and did not develop dSINE. The risk factors for the development of dSINE and the treatment of dSINE were analyzed. Results: dSINE occurred postoperatively in nine patients (12.9%) with a median time frame of 17.7±11.7 months. The incidence of dSINE did not differ significantly according to classification, phase of dissection, or oversizing. All patients in the dSINE group developed enlargement of the false lumen. dSINE closure was successfully achieved without complications via thoracic endovascular aortic repair (TEVAR) in all patients. Conclusion: No independent factors predicting the development of dSINE were noted in this study. Additional TEVAR for dSINE provides good results and achieves false lumen thrombosis in the thoracic aorta, with no complications.

OBJECTIVES This study was conducted to examine the incidence and modes of the bioprosthetic valve failure of the porcine valve in the mitral position and compare them with those of the pericardial valve. METHODS This study included 240 patients (116 men [48.3%]; mean age, 74.87 ± 6.61 years) who underwent mitral valve replacement using the St. Jude Medical Epic bioprosthesis (Epic) (N = 125) or Carpentier–Edwards Perimount (CEP) pericardial valve (N = 115) from January 2000 to December 2020. RESULTS The median clinical follow-up durations in the Epic and CEP groups were 54.5 months (range, 0–111 months) and 81.5 months (range, 0–194 months), respectively. Structural valve degeneration (SVD) was observed in 9 patients (7.2%) in the Epic group and 11 patients (9.6%) in the CEP group. The rates of freedom from SVD at 3, 5 and 7 years were 97.7%, 90.5% and 75.5% in the Epic group and 100.0%, 96.1% and 90.0% in the CEP group, respectively. SVD reoperation was performed for 7 patients (5.6%) in the Epic group and 6 patients (5.2%) in the CEP group. The rates of freedom from SVD reoperation at 3, 5 and 7 years were 97.7%, 90.5% and 75.5% in the Epic group and 100%, 96.1% and 90.0% in the CEP group, respectively. Epic SVD was predominantly due to leaflet tearing, whereas CEP SVD was predominantly due to leaflet calcification and adhesion to the subvalvular apparatus. CONCLUSIONS SVD of the porcine valve was predominantly due to leaflet tearing. The rate of reoperation for SVD was slightly higher for the porcine valve in the mitral position than for the pericardial valve at adjusted survival analysis.

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Caseous calcification of mitral annulus CCMA is rare variant of mitral annular calcification MAC . There is no clear consensus on the optimal management for CCMA. However, patients with CCMA have high risk of embolic strokes. We performed drainage and debridement in 3-cases of CCMA. All patients had a history of chronic kidney disease CKD and two of the three patients were undergoing hemodialysis. If a calcified mass at the mitral valve annulus is observed, especially in hemodialysis patients, CCMA should be recognized.

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A 67-year-old woman had aseptic mediastinal abscess during oral steroids treatment for myelodysplastic syndrome(MDS)and Tolosa-Hunt syndrome 15 years ago, and underwent left thoracotomy drainage. The postoperative wound was ulcerated and was diagnosed with pyoderma gangrenosum. She had heart failure symptoms and was diagnosed with severe aortic valve regurgitation(AR)two years ago. Although surgery was indicated at another hospital, they judged that the risk of complications including wound infection and mediastinal abscess was high, and the patient was followed up with medical therapy. However, the symptoms of heart failure gradually worsened, and we planned aortic valve replacement through right anterior mini-thoracotomy. Her postoperative course was unremarkable, and she underwent extubation on the day of the operation and was discharged 12 days postoperatively without complications. We suggest that the right small thoracotomy approach will be useful for patients at high risk of mediastinal abscess and wound infection.

Objectives This study aimed to examine very-long-term outcomes of a mechanical valve at the mitral position. Methods This study included all patients who underwent mitral valve replacement using a mechanical valve including urgent operation at the Department of Cardiovascular Surgery, Hyogo Brain and Heart Center, Himeji, from January 1987 to December 2015. Results Five hundred and eighty three patients (277 men [47.51%]; age, 61 [54–67] years) were included in this study. The implanted valve models were as follows: SJM 221(37.91%), ATS 35(6.00%), On-X 68(11.66%), and Carbomedics 194(33.28%).The median clinical follow-up duration was 13.3 (7.4–19.6) years. The survival rates at 10, 15, 20, and 25 years were 81.42%, 69.27%, 56.34%, and 45.03%, respectively. Thromboembolism was observed in 38 patients, and the linearized ratio for each event was 0.626%/patient-year(95% confidence interval, 0.443%–0.859%). Intracranial Haemorrhage and gastrointestinal bleeding were observed in 26 and 9 patients, and the linearized ratio for each event was 0.425%/patient-year (95% confidence interval, 0.277%–0.006%) and 0.145%/patient-year (95% confidence interval, 0.067%–0.276%), respectively. Major paravalvular leak was observed in 32 patients, and the linearized ratio was 0.532%/patient-year (95% confidence interval, 0.364%–0.751%). The cumulative incidence rate of major paravalvular leak at 10, 15, 20, and 25 years were 3.7%, 5.6%, 6.4%, and 10.4%, respectively. Multivariable Cox regression analysis revealed that repeated mitral valve replacement and male gender were associated with major paravalvular leak. Conclusion Male gender and repeated mitral valve replacement were risk factors for paravalvular leak after mechanical mitral valve replacement. Paravalvular leak could have occurred regardless of postoperative period even at 25 years after implantation. Lifelong clinical follow-up is considered necessary.

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