Objective: The presence of a short, angulated neck in endovascular aneurysm repair remains challenging. The fish-mouth shape of the AORFIX AAA endograft enables trans-renal fixation, which can be advantageous in such cases. However, it is difficult to align the bottom line of the fish-mouth in a renal artery with an angulated neck. Here we devised a breakthrough technique to facilitate accurate fish-mouth positioning and achieved positive results. We then observed the ex vivo behavior of fish-mouth fixation of the AORFIX AAA endograft using this technique. Methods: A model of an abdominal aorta with a renal artery was created of porcine aortic vessels. Typical proximal touch-up ballooning was performed for reference. Kissing touch-up ballooning, which we named the Aligning Orifice of the Renal artery with fish-mouth FIXation (AORFIX) technique, between the aorta and the renal artery was performed as an interventional model. Results: In the reference model in which the endograft was deployed just below the renal artery, the bottom line of the fish-mouth was raised to cover the renal artery via touch-up ballooning. Unfortunately, its position did not improve with balloon angioplasty of the renal artery because the ring stents returned to the covered position after balloon deflation. In another reference model in which the endograft was deployed far enough below the renal artery, the bottom line of fish-mouth wasn't raised beyond that. In the interventional model with the AORFIX technique, the bottom line of the fish-mouth was anchored at the lower end of the renal artery orifice. The ring stents were shaped to fit the orifice, and clearance of the renal artery was secured. Conclusion: This ex vivo observations of fish-mouth behavior support our surgical experiences. The AORFIX technique effectively affixed the fish-mouth to the renal artery orifice and created a longer-lasting effect. These results suggest that the AORFIX technique can be a good option in cases of challenging endovascular aneurysm repair with a short, angulated neck.

We present the case of a 72-year-old male with Inspiris RESILIA aortic valve (Inspiris) transvalvular leakage during surgical aortic valve replacement (AVR). The patient initially underwent AVR for aortic regurgitation with a bicuspid aortic valve at the age of 64. By the age of 72, the valve had deteriorated and it was assessed that redoing the AVR was necessary. The Inspiris was inserted in the supra-annular position using the non-everting mattress suture technique with a COR-KNOT. During weaning off from cardiopulmonary bypass, transesophageal echocardiography (TEE) captured unfamiliar turbulent flows from the three stent posts. Further TEE revealed that these flows originated from the base of the stent posts, which gradually decreased and disappeared by the end of the surgery after administration of protamine. The patient has been discharged uneventfully. Paravalvular leakage has not been observed during the postoperative course and we could not find TVL in TEE 2 months postoperatively. While considering the detailed mechanism, it is possible that there is no need for re-exploration concerning three directional TVL in the Inspiris.

A 65-year-old male was diagnosed with severe aortic stenosis with an indication for surgery and referred to our department. The patient opted for aortic valve replacement using a bioprosthesis. Due to the patient's relatively small native aortic valve area, a concurrent root dilatation maneuver (Bo Yang method) was performed to prevent patient-prosthetic mismatch and to allow for the implantation of a sufficiently larger bioprosthesis, facilitating the valve-in-valve procedure. The successful implantation of an Inspiris 25-mm bioprosthesis was achieved. Post-operative 3D-computed tomography revealed no tilting or misalignment of the bioprosthesis, and a properly sized, undistorted Valsalva sinus was observed. Aortic valve replacement using the Bo Yang root enlargement technique is considered a promising alternative for relatively younger patients requiring aortic valve intervention.

We report a case of redo mitral valve replacement (MVR) for a Björk-Shiley Delrin valve implanted 47 years previously. A 71-year-old man initially underwent MVR for mitral regurgitation at our hospital at the age of 16 years. Following the operation, follow-up examinations were performed at the outpatient clinic and annual transthoracic echocardiogram findings showed only mild mitral regurgitation, with no adverse events noted. However, a transthoracic echocardiogram examination performed 45 years after the operation revealed mild to moderate mitral regurgitation, while dyspnea with exertion was also noted at that time. As part of a more detailed examination, transesophageal echocardiogram results showed moderate transvalvular leakage. Redo MVR was subsequently performed under the diagnosis of prosthetic valve dysfunction. Analysis of the explanted prosthetic valve revealed wear of the Delrin disk, and widening of the gap between the disk and strut, which were presumed to be the cause of transvalvular leakage. A half century has passed since introduction of the Björk-Shiley valve and the present is a rare case of valve malfunction. Presented here are related details, along with a review of existing literature and results of Björk-Shiley valve use at our hospital.