An 84-year-old man underwent transcatheter aortic valve replacement (TAVR) for severe aortic stenosis with heart failure. Paravalvular leak (PVL) of the aortic valve was observed immediately after the operation, and the heart failure was difficult to manage; closure with a vascular plug was attempted, but PVL did not improve. Therefore, four months after TAVR, the decision was made to perform surgical aortic valve replacement (SAVR). The operation was expected to take a long time due to the concomitant mitral valve replacement, ascending aortic valve replacement and pulmonary vein isolation, in addition to SAVR with removal of the TAVR valve, so a rapid deployment valve was used for aortic valve replacement. The patient's postoperative course was good, with no complications. Postoperative echocardiography showed no problems with the replaced aortic or mitral valves. Twenty-six days after surgery, the patient was discharged home, although it took time for rehabilitation due to the long hospital stay after TAVR. More than two years have passed since the surgery, and the patient is currently an outpatient with no symptoms of heart failure. The present report describes the use of a rapid deployment valve for surgical AVR after TAVR with good results.

Introduction
 Recently, foreign residents' difficulties using the Japanese medical system are being acknowledged. This study investigates the case of the medical intake forms, monshinhyo, that new patients at Japanese medical facilities must complete.Many patients, especially non-native ones, find them difficult.
Method
 First, 6 foreign and 6 Japanese students (hereafter, FS and JS) at 4-year universities were interviewed regarding their understanding of monshinhyo taken from three different departments -obstetrical, surgical, and internal medicine - at a hospital in Kansai; then, a questionnaire was developed and given to 25 FS and 85 JS.
Results
 Both FS and JS noted language problems. JS could pronounce medical terms better than FS but comprehended them only about as well as FS. Moreover, both FS and JS found the styles, layouts, and purposes of some questions unclear, and they sometimes had to guess the details of what monshinhyo requested. These included questions involving symptoms, divisions of medical departments, and semantic range of terms for blood relations. Also, medical practices/norms not found in the native country sometimes puzzled FS.
Conclusions
 Problems with monshinhyo arise from both the patients' side-Japanese as well as foreign-due to limited medical-related vocabulary/kanji and/or a lack of experience using Japanese medical services, and the monshinhyo themselves, due to their inclusion of unclear questions and ambiguous expressions. Probably, monshinhyo's authors' familiarity with medical terms and the Japanese medical system caused them to take for granted more knowledge than many patients actually have. To improve medical services, therefore, we suggest reexamining and reorganizing questions that already exist, introducing multiple choice and yes/no questions when possible, and providing furigana for kanji. Fundamentally, throughout the medical system, patients should be able to understand all the language they encounter. Clarifying the language, cultural assumptions, and purpose(s) of monshinhyo is a good starting point.