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Current guidelines equally recommend direct oral anticoagulants (DOACs) and warfarin for atrial fibrillation (AF) patients with a bioprosthetic valve (BPV); however, there are limited data comparing DOACs and warfarin in AF patients with an aortic BPV.Methods and Results: This post-hoc subgroup analysis of a multicenter, prospective, observational registry (BPV-AF Registry) aimed to compare DOACs and warfarin in AF patients with an aortic BPV. The primary outcome was a composite of stroke, systemic embolism, major bleeding, heart failure requiring hospitalization, all-cause death, or BPV reoperation. The analysis included 479 patients (warfarin group, n=258; DOAC group, n=221). Surgical aortic valve replacement was performed in 74.4% and 36.7% of patients in the warfarin and DOAC groups, respectively. During a mean follow up of 15.5 months, the primary outcome occurred in 45 (17.4%) and 32 (14.5%) patients in the warfarin and DOAC groups, respectively. No significant difference was found in the primary outcome between the 2 groups (adjusted hazard ratio: 0.88, 95% confidence interval: 0.51-1.50). No significant multiplicative interaction was observed between the anticoagulant effects and type of aortic valve procedure (P=0.577).Among AF patients with an aortic BPV, no significant difference was observed in the composite outcome of adverse clinical events between patients treated with warfarin and those treated with DOACs, suggesting that DOACs can be used as alternatives to warfarin in these patients.

BACKGROUND Collagen disease is an important cause of aortic regurgitation (AR). Although aortic valve surgery is recommended for patients with AR and depressed left ventricular (LV) function, there have been few reports about risk factors for LV dysfunction in patients with AR concomitant with collagen disease. METHODS AND RESULTS We conducted this study at Kumamoto University Hospital in Japan. A total of 41 patients who had moderate to severe AR and concomitant collagen disease between January 2014 and December 2019 were enrolled. With regard to baseline characteristics, there were no significant differences in the type of collagen disease or El Khoury class between patients with preserved LV function and those with reduced LV function. B-type natriuretic peptide (375.2 [257.9-3852.6]pg/ml vs. 64.0 [33.3-133.6]pg/ml, p

OBJECTIVES This study aimed to assess the long-term outcomes and investigate the factors related to left ventricular (LV) reverse remodelling after aortic valve replacement (AVR) in patients with chronic aortic regurgitation (AR). METHODS A total of 246 patients who underwent AVR for chronic AR at our institution were included in this retrospective study. Primary end-points included all-cause mortality, cardiac mortality and major adverse cerebral and cardiovascular events. Secondary end-points included cardiac function on echocardiography 1 year after surgery. We explored the predictive factors for reverse remodelling 1 year after surgery. RESULTS The 10-year survival rate was 86.0%, with no cardiac deaths in 93.8% and no major adverse cerebral and cardiovascular events in 79.9% of patients. Postoperative LV function and symptoms were significantly improved 1 year after surgery, but 34 patients (13.8%) did not recover normal function and structure. A significant negative correlation was found between the incidence of cardiac death and major adverse cerebral and cardiovascular events and reverse remodelling. Multivariate logistic regression identified preoperative LV ejection fraction (P = 0.001, odds ratio = 1.057) and LV end-systolic dimension index (P = 0.038, odds ratio = 0.912) as significant predictive factors of reverse remodelling 1 year after surgery. CONCLUSIONS Preoperative LV ejection fraction and LV end-systolic dimension index were predictive factors for reverse remodelling after surgery, which was associated with late outcomes. Earlier surgery may thus help to restore normal LV function and achieve better late outcomes after AVR for AR.

We report a 65-year-old man who underwent aortic valve replacement because of severe aortic stenosis associated with de novo iatrogenic variant transthyretin amyloidosis derived from a liver graft extracted from a patient with hereditary transthyretin amyloidosis 9 years after the domino liver transplantation. (Level of Difficulty: Advanced.), Graphical abstract, We report a 65-year-old man who underwent aortic valve replacement because of severe aortic stenosis associated with de novo iatrogenic variant…

Graphical abstract, Highlights • L-wave is caused by abrupt elevation and gradual decrease of LV diastolic pressure. • Color M-mode echocardiography demonstrates “L” wave of LA slow propagation. • Pulmonary venous reservoir function and LA conduit function caused diastolic LA flow.

Background Chronic mitral regurgitation can be primary (degenerative) or secondary (functional); each has its own aetiology, treatment approach, and prognosis. A combination of the two types of regurgitation can lead to unexpected haemodynamic changes. Case summary A 72-year-old woman presented to our hospital with dyspnoea on exertion, moist cough, and orthopnoea. At admission, transthoracic echocardiography (TTE) findings revealed severely reduced left ventricular ejection fraction, dilation of the left ventricle and left atrium, mild mitral regurgitation with prolapse of the posterior leaflet, and bilateral leaflet tethering. She was diagnosed with idiopathic cardiomyopathy with mild mitral regurgitation. After compensation of heart failure, angiotensin-receptor blocker and beta-blocker treatment were initiated, and the dose was subsequently titrated. At 7 months after initiating medical therapy, TTE showed significant improvement of the left ventricular ejection fraction, disappearance of left ventricular dilation (reverse remodelling), and mitral valve tethering. However, posterior leaflet prolapse became apparent, and mitral regurgitation blowing became more severe. Chordal lengthening, leaflet thickening, and degeneration were observed, but there were no ruptured chordae. Successful surgical repair of the mitral and tricuspid valves was performed. Discussion In this unusual mitral regurgitation case, the regurgitation worsened following an improvement of cardiac function due to the loss of tethering from a reduction of the left ventricular diameter and an increase in closing force by increasing the left ventricular contractile force. Eventually, mitral regurgitation prolapse became apparent. Therefore, we should consider that reverse remodelling may exacerbate mitral regurgitation.

BACKGROUND Although bioprosthetic valve (BPV) replacements are becoming more common within our aging society, there are limited prospective data on the appropriate antithrombotic therapy for East Asian patients with atrial fibrillation (AF) and BPV replacement. Antithrombotic therapy and thrombotic and hemorrhagic event rates in Japanese patients with AF and BPV replacement are investigated.Methods and Results:This multicenter, prospective, observational study enrolled patients with BPV replacement and AF. The primary efficacy outcome was stroke or systemic embolism, and the primary safety outcome was major bleeding. Of the 894 patients analyzed, 54.7%, 29.4%, and 9.6%, were treated with warfarin-based therapy, direct oral anticoagulant (DOAC)-based therapy, or antiplatelet therapy without anticoagulants, respectively; 6.3% did not receive any antithrombotic drugs. The mean observation period was 15.3±4.0 months. The event rates for stroke or systemic embolism and major bleeding were 1.95%/year and 1.86%/year, respectively. The multivariate adjusted hazard ratios for DOAC vs. warfarin were 1.02 (95% confidence intervals [CI], 0.30-3.41 [P=0.979]) for systemic embolic events and 0.96 (95% CI, 0.29-3.16 [P=0.945]) for major bleeding. CONCLUSIONS Approximately 30% of patients with AF and BPV replacement were treated with DOAC. The risks of major bleeding and stroke or systemic embolism were similar between warfarin- and DOAC-treated patients with AF who had BPV replacement. Treatment with DOACs could be an alternative to warfarin in this population.

A 68-year-old man who had undergone descending thoracic aortic replacement was referred to our hospital with a thoracoabdominal aortic aneurysm. During the original surgery, the Adamkiewicz artery was directly reconstructed. However, multidetector row computed tomography showed occlusion of the reconstructed artery at its orifice, with supply by a collateral vessel from the left lateral thoracic artery. With careful incision to avoid damage to the collateral vessel, no postoperative neurological deficit was observed.

BACKGROUND While there is a concern about the increase in the occurrence of acute aortic dissection (AAD) caused by the worsening of hypertension, mental stress, etc., there is a lack of data regarding the influence of disasters on this event. The aim of this study was to address this issue in the acute–subacute phase after the Kumamoto Earthquake occurred on 14 April 2016. METHODS We retrospectively investigated the impacts of the Kumamoto Earthquake on various cardiovascular diseases, including AAD, utilizing the medical records of patients in 16 hospitals in Kumamoto Prefecture during the period from 14 April to 30 June (78 days) in 2014, 2015, 2016, and 2017. RESULTS The occurrence of heart failure and venous thromboembolism increased significantly in the acute–subacute phase after the earthquake. When comparing the earthquake year (2016) to the non-earthquake years (2014, 2015, and 2017), the difference in the occurrences and mortalities of AADs were not significant. When other characteristics of the patients were compared between the earthquake year and the non-earthquake years, there were no differences. CONCLUSIONS It might be possible that the Kumamoto Earthquake did not affect the incidence of AAD or deaths from AAD, possibly because the climate was mild and the preventive efforts based on previous experience were successful. REGISTRATION University Hospital Medical Information Network (UMIN)-CTR (http://www.umin.ac.jp/ctr/). IDENTIFIER UMIN000023864. PUBLIC ACCESS INFORMATION Opt-out materials were available at the following website: http://www.kumadai-junnai.com/home/wp-content/uploads/shinsai.pdf.

Highlights • Recurrent embolism originated from the persistent persistent sciatic artery aneurysm. • Distal bypass was required due to the anomaly position of popliteal artery. • Persistent sciatic artery aneurysm is rare, but remember in especially acute limb ischemia., Introduction Persistent sciatic artery (PSA) is a rare congenital vascular anomaly. It has several clinical features with the formation of aneurysms. Among the complications, leg ischemia is severe problem and the management involves revascularization and prevention of recurrence. We herein describe an anatomically annoying case of PSA aneurysm with recurrent embolism that necessitated thrombectomy and bypass surgery. And this work has been reported in line with the SCARE criteria. Case presentation A 76-year-old woman developed leg embolism twice from PSA aneurysm. PSA was complete type and the popliteal artery ran on the lateral side, which was difficult to approach from the standard medial side. Based on these anatomical conditions, thrombectomy of the posterior-tibial artery (PTA) and femoral-PTA bypass were performed. Additionally, the proximal side of PTA from the anastomosis site was ligated to avoid the recurrence of embolism. Residual PSA aneurysm has not yet been treated, but neither clinical complications nor dilatation have occurred. Discussion PSA is a rare disease, but should be remember in acute limb ischemia. Clear treatments have not yet been established; therefore, its plans need to be considered based on clinical symptoms and anatomical conditions. Conclusion Although there were anatomical issues in the present case, thrombectomy and bypass surgery were successful and no complications have occurred one year after surgery.

Left atrial intramural hematoma is a rare complication of percutaneous coronary intervention. The combination treatment with surgery and interventional therapy is one of therapeutic options.

Objective Because the presence of immunocompetent cells in the myocardium is associated with the pathological stage and/or myocardial viability, we explored relationships between functional recovery after left ventricular assist device implantation and the distribution of immunocompetent cells in non-ischaemic dilated cardiomyopathy patients. Methods We reviewed 50 consecutive dilated cardiomyopathy patients implanted with HeartMate II at our institute between April 2013 and December 2018 who were treated with optimal medical therapy during left ventricular assist device support. Patients were stratified by improvement of the left ventricular ejection fraction at 6 months after implantation: ≥ 10% increase (Gr ≥ 10%), 5–10% (Gr 5–10%), and ≤ 5% (Gr ≤ 5%). T cells and macrophages were evaluated in the apical myocardium after left ventricular assist device implantation. Results During left ventricular assist device support, 12 patients underwent heart transplantation and 2 patients died. Four patients with Gr ≤ 5% were readmitted because of congestive heart failure, but none with Gr ≥ 10%. Macrophages and T cells in the left ventricular myocardium with Gr ≥ 10% were significantly more present compared to those in other groups. Conclusions The distribution of immunocompetent cells in the left ventricular myocardium might predict myocardial viability of this pathology after implantation.

We aimed to investigate the correlation of graft flow measurements between transit-time flow measurement (TTFM) during coronary artery bypass grafting (CABG) surgery and dynamic cardiac CT after the surgery. Fourteen patients underwent CABG with TTFM and postoperative dynamic cardiac CT; 11 internal thoracic artery (ITA) grafts and 15 saphenous venous grafts (SVGs) were included for analysis. Pearsons correlation analysis was performed for the comparisons of the TTFM and cardiac dynamic CT flow parameters. TTFM was not significantly correlated with the CT flow of the ITA grafts (r = −0.23, P = .49), but it had a very strong correlation with the CT flow of the SVGs (r = 0.83, P

Aims: Although the bacterial virulent factor of cytotoxin-associated gene-A (CagA)-seropositivity and the host genetic factors of interleukin (IL)-1 polymorphisms have been suggested to influence Helicobacter pylori (HP) -related diseases, the underlying mechanisms of the association between HP infection and acute coronary syndrome (ACS) remain unknown. Methods and results: Among 341 consecutive ACS patients, the clinical outcomes after ACS included composite cardiovascular events within the 2-year follow-up period.A significantly higher probability of primary outcomes was observed in HP positive patients than in HP negative patients. There were no significant differences in the rate of cardiovascular events between HP positive and HP negative patients in the absence of an IL-polymorphism, while there were significant differences in the presence of an IL-polymorphism. There were significant differences in the rate of cardiovascular events among CagA positive, CagA negative/ HP positive and CagA negative/HP negative patients. Moreover, via immunohistochemical staining, aortic CagA positive cells were confirmed in the vasa vasorum in CagA positive patients, whereas they could not be identified in CagA negative patients. Conclusions: The bacterial virulence factor CagA and host genetic IL-1 polymorphisms influence the incidence of adverse cardiovascular events, possibly through infection of atherosclerotic lesions.Registration: University Hospital Medical Information Network (UMIN)-CTR (http://www.umin.ac.jp/ctr/).Identifier: UMIN000035696. Keywords: Helicobacter pylori, CagA, Interleukin-1, MACE

Aims Bleeding is a serious complication in patients with continuous‐flow left ventricular assist device (CF‐LVAD). Acquired von Willebrand syndrome (AVWS; type 2A) develops because of high shear stress inside the pumps and is a cause of bleeding complication. Although von Willebrand factor (vWF) multimer analysis is useful for diagnosing AVWS, it is only performed in specialized research institutes. A novel microchip flow chamber system, the total thrombus‐formation analysis system (T‐TAS), is a point‐of‐care system to evaluate the thrombus‐formation process and useful for monitoring platelet thrombus‐formation capacity in patients receiving antiplatelet therapy and the diagnosis and evaluation of the clinical severity of von Willebrand disease type 1. However, little is known about the association between AVWS and platelet thrombus‐formation capacity evaluated by T‐TAS in patients with CF‐LVAD. We aimed to evaluate the utility of T‐TAS for easy detection of AVWS in patients with CF‐LVAD. Methods and results We simultaneously evaluated the vWF large multimers and T‐TAS parameters in four consecutive patients with axial‐type CF‐LVAD and eight control patients treated with aspirin and warfarin. vWF large multimer index was defined as the proportion of large multimers in total vWF derived from a normal control plasma. T‐TAS analyses different thrombus‐formation processes using two microchips with different thrombogenic surfaces. PL24‐AUC10 levels in the platelet (PL) chip are highly sensitive for platelet functions, while AR10‐AUC30 levels in the atheroma (AR) chip allow the assessment of the overall haemostatic ability. vWF large multimer index and T‐TAS parameters were decreased in all patients with CF‐LVAD. The mean PL24‐AUC10 level (5.4 ± 2.9 vs. 219 ± 67; P

Objectives This study aimed to evaluate the causes of initial mitral valve (MV) repair failure, the details of reoperation and the long-term outcomes of mitral valve re-repair (Re-MVP). Methods We retrospectively reviewed 86 patients who underwent reoperation after MV repair for MR due to degenerative disease from October 1991 to December 2015. First, we analysed the initial MV repair data, causes of MV repair failure, reoperation data and long-term outcomes including survival. Second, the patients were classified into 2 groups based on valve related failure or procedure related failure , and the differences between the groups were analysed. Results Leaflet prolapse at the initial operation affected the bilateral leaflets in 37 (43%) patients, the anterior leaflet in 30 (35%) patients and the posterior leaftlet in 19 (22%) patients. Median duration from first operation to reoperation was 47.5 (interquartile range 4.8-85.8) months. Reoperation indication included recurrent mitral regurgitation alone in 59 patients, haemolysis combined with recurrent mitral regurgitation in 15 patients, infectious endocarditis combined with recurrent mitral regurgitation in 8 patients, mitral stenosis in 2 patients and left ventricular pseudoaneurysm in 2 patients. The cause of MV repair failure was valve-related in 61 (71%) patients, procedure-related in 20 (23%) patients and both in 5 (6%) patients. Re-MVP was successful in 23 (27%) patients. Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Freedom from all-cause death was significantly better after Re-MVP. The 5-year freedom from reoperation after Re-MVP was 95.7%. Conclusions Re-MVP was more common in patients with procedure-related failure, which occurred earlier than valve-related failure. Durability of re-repaired MVs and survival of re-repaired patients were acceptable.

Objective: To evaluate limb-salvage surgery including vascular resection for lower-extremity soft-tissue sarcomas and carcinomas for adult patients. Materials and Methods: Eight consecutive patients (median age, 59 years) who underwent vascular replacement during surgery for malignant tumors in the lower limbs between November 2006 and March 2018 were evaluated. Patient data were retrospectively obtained in a computerized database. Arterial and venous reconstructions were performed for seven patients, with one additional patient receiving venous reconstruction only. Autologous-vein (n=6) and synthetic bypasses were used for arterial repairs, whereas only autologous veins were implanted for venous repairs. Results: Morbidity was 62.5%, and in-hospital mortality was 12.5%. At a median follow-up of 24 months, the primary patency rates of arterial and venous reconstructions were 85.7% and 62.5%, respectively. Limb salvage was achieved in all cases. Conclusion: Early and mid-term bypass patency rates, the high percentage of limb salvage, and the oncologic outcome underline the efficacy of en bloc resection of soft-tissue tumors involving major vessels of the lower limbs. The anticipated need for vascular resection and reconstruction should not be a contraindication to sarcoma and carcinoma resections. However, efforts to achieve better control over systemic spread are required for long-term survival.

OBJECTIVES To evaluate whether the preoperative Synergy between Percutaneous Coronary Intervention with TAXUS and Cardiac Surgery (SYNTAX) score was associated with late outcomes of coronary endarterectomy (CE) for the diffusely diseased left anterior descending artery (LAD). METHODS We retrospectively analysed 205 of 212 patients undergoing CE for the diffusely diseased LAD between September 2004 and May 2016, excluding 2 patients without preoperative angiographic data and 5 redo cases. The mean SYNTAX score was 34.6. Patients were divided into 3 groups according to their SYNTAX score: low (≤22, n = 26), intermediate (23-32, n = 58) and high (≥33, n = 121). The study end-points were cardiac death and major adverse cardiac and cerebrovascular events, defined as all-cause death, cerebrovascular accidents, non-fatal myocardial infarction and repeat revascularization. All CEs involved long arteriotomy and the reconstruction of the endarterectomized LAD using the skeletonized internal thoracic artery. RESULTS Postoperative mortality and morbidity were similar between the groups. The median follow-up period was 5.4 years. We found no significant difference in the cumulative cardiac death-free survival rate at 5 years (91.1% vs 100% vs 98.3%; log-rank, P = 0.196) or major adverse cardiac and cerebrovascular events (61.6% vs 71.5% vs 76.7%; log-rank, P = 0.258) in the low, intermediate and high SYNTAX score groups, respectively. Univariate and multivariate Cox proportional hazard analyses revealed no significant association between the study end-points and individual components of the SYNTAX score for the LAD. CONCLUSIONS The preoperative SYNTAX score and its individual components for the LAD were not associated with late outcomes following CE for the diffusely diseased LAD.

A 74-year-old man was admitted to our hospital with chest pain and dyspnea associated with ST elevation in leads II, III and aVF. An echocardiogram showed an enlarged mass lesion measuring nearly 80 mm. Coronary angiography showed two giant coronary artery aneurysms (CAAs) in the right coronary artery (RCA). CAAs were also seen in the left main trunk and left anterior descending artery. Computed tomography showed the CAA in the RCA was ruptured into the right atrium. We therefore diagnosed this patient with multiple CAAs, myocardial infarction and coronary artery rupture. He underwent successful surgical excision and coronary bypass surgery.

Although radiation therapy is widely used to treat breast cancer, high doses of radiation may cause various complications. We report a case of a left ventricular aneurysm complicated with an intractable skin ulcer caused by radiation therapy for breast cancer. The communication between the aneurysm and skin ulcer caused severe bleeding. An urgent left ventricular repair and chest wall reconstruction with a rectus abdominis flap were performed successfully.

Purpose To evaluate the self-assessed competency of graduating residents (GRs) in Japan upon completion of their residency and to identify the gap between their competency and the competency expected by their program directors (PDs). Method A list of 31 essential surgical procedures was compiled according to the consensus of surgical educators from around the country. A survey with this list was sent to all 909 GRs and their 611 PDs in 2016. The GRs rated their competency to perform these procedures and the PDs were asked to evaluate the expected competency of their GRs using the Zwisch Scale. Result The response rate was 56.3% for the GRs and 76.8% for the PDs. Fewer than half of the GRs who responded felt confident performing ten (32%) of the surgical procedures evaluated. For most procedures, the GRs' self-reported competency was lower than the expectation reported by their PDs. This gap was more than 10% for 13 of the procedures. Conclusion More than half of the GRs in Japan lacked the confidence in their skill to perform one-third of the surgical procedures selected for evaluation in this study. These findings should be used to update the surgical education curriculum in Japan.

OBJECTIVES This study was aimed to investigate the impact of preoperative renal malperfusion on early and late outcomes after surgery for acute type A aortic dissection (AAAD). METHODS Of 915 patients who underwent surgery for AAAD between September 2004 and September 2017, we enrolled 534 patients whose preoperative enhanced computed tomography images were retrospectively available in this study. Exclusion criteria were single kidney (n = 3) and dialysis-dependent preoperatively (n = 12). We compared early and late outcomes between patients who had preoperative renal malperfusion (n = 64) and those who did not have renal malperfusion (n = 470). RESULTS The incidence of postoperative acute kidney injury, defined using the Kidney Disease: Improving Global Outcomes criteria, was higher in the renal malperfusion group than in the no renal malperfusion group (76.6% vs 39.4%; P CONCLUSIONS Preoperative renal malperfusion is an independent predictor for postoperative acute kidney injury and operative death but not associated with late mortality after surgery for acute type A aortic dissection.

Objectives Early saphenous vein graft (SVG) occlusion is typically attributed to technical factors. We aimed at exploring clinical, anatomical, and operative factors associated with the risk of early SVG occlusion (within 12 months postsurgery). Methods Published literature in MEDLINE was searched for studies reporting the incidence of early SVG occlusion. Individual patient data (IPD) on early SVG occlusion were used from the SAFINOUS-CABG Consortium. A derivation (n = 1492 patients) and validation (n = 372 patients) cohort were used for model training (with 10-fold cross-validation) and external validation respectively. Results In aggregate data meta-analysis (48 studies, 41,530 SVGs) the pooled estimate for early SVG occlusion was 11%. The developed IPD model for early SVG occlusion, which included clinical, anatomical, and operative characteristics (age, sex, dyslipidemia, diabetes mellitus, smoking, serum creatinine, endoscopic vein harvesting, use of complex grafts, grafted target vessel, and number of SVGs), had good performance in the derivation (c-index = 0.744; 95% confidence interval [CI], 0.701-0.774) and validation cohort (c-index = 0.734; 95% CI, 0.659-0.809). Based on this model. we constructed a simplified 12-variable risk score system (SAFINOUS score) with good performance for early SVG occlusion (c-index = 0.700, 95% CI, 0.684-0.716). Conclusions From a large international IPD collaboration, we developed a novel risk score to assess the individualized risk for early SVG occlusion. The SAFINOUS risk score could be used to identify patients that are more likely to benefit from aggressive treatment strategies.

Background Mitral valve surgery in patients with severe mitral annular calcification can be challenging. We investigated surgical outcomes of mitral valve surgery with complete annular decalcification and reconstruction. Methods Between January 2004 and December 2013, 2,104 patients underwent mitral valve surgery at our institution. Of these, 61 patients (mean age 70 years) with severe mitral annular calcification were reviewed. Valve lesions were stenosis in 20 patients (32.8%), regurgitation in 16 (26.2%), mixed in 19 (31.1%), and prosthetic valve dehiscence in 6 (9.8%). Calcified annulus was resected completely and reconstructed with equine pericardium in 48 patients (78.7%), autologous pericardium in 10 (16.4%), and polytetrafluoroethylene felt pledgets in 3 (4.9%). Mitral valve repair was attempted in 4 patients (6.6%) and mitral valve replacement in 57 (93.4%). One patient (1.6%) had conversion from repair to replacement due to cardiac rupture. Concomitant procedures included aortic valve replacement in 36 patients (56.3%), tricuspid valve surgery in 28 (43.8%), and coronary artery bypass graft surgery in 18 (28.1%). Mean follow-up was 3.5 ± 2.5 years. Results There was no 30-day hospital death. Early complications were left ventricular pseudoaneurysm in 1 patient, pericardial patch dehiscence in 1, severe arrhythmia in 6, and stroke in 2. At 5 years, rates of survival and freedom from cardiac death and major adverse valve-related events were 75.6%, 79.7%, and 72.7%, respectively. Multivariate analysis indicated coronary artery disease as an independent predictor of cardiac death. Conclusions In patients with severe mitral annular calcification undergoing mitral valve surgery, complete annular decalcification and reconstruction yields favorable outcomes.