A 51-year-old woman with a 12-year history of chronic hemodialysis and secondary hyperparathyroidism suffered dyspnea induced by massive mitral regurgitation due to severe circular mitral annular calcification. Her anterior mitral leaflet was resected and successfully replaced with a 25mm SJM valve in the supra-annular position. The posterior leaflet was heavily calcified and adhered to the left ventricle. The flangeless prosthesis was directly implanted into the left atrial wall on the calcified annulus. Postoperative cine fluoroscopy and echocardiography showed good hemodynamic performance of the prosthesis without perivalvular leakage. In cases of mitral annular calcification due to chronic renal failure, the SJM valve is a more suitable valve prosthesis for replacement of the mitral valve in the supra-annular position. Supra-annular mitral valve replacement without a flange may give superior valve-performance compared to valves with a flange considering thrombogenicity and left ventricular function. However, we may still have to consider the indication of a supra-annular mitral valve replacement with a flange in cases with wide mitral annular calcification in the giant left atrium.

A 68-year-old male was admitted as an emergency case because of two severe back pain episodes in one week. Chest X-ray showed a marked prominence of the aortic knob. A remarkable bulging of the distal aortic arch and a crescentic low density area along the descending aorta on enhanced chest CT suggested a closing aortic dissection. Operation revealed extensive collapse of the very fragile intima of the aneurysmal wall and extraluminal hematoma along the descending aorta due to bleeding from the ruptured site. The ruptured aneurysm of this type should be accurately differentiated from the DeBakey type III closing aortic dissection which can be followed up medically.