An 82-year-old man was referred to our department for surgery because of severe prosthetic aortic valve stenosis and mitral regurgitation. He had undergone sutureless aortic valve replacement (Perceval S Medium, LivaNova, London, UK) 6 years previously. He also had chronic kidney disease requiring hemodialysis, diabetes, hypertension, and gastric submucosal tumor.

Transthoracic echocardiography revealed a mean aortic transvalvular pressure gradient of 68 mmHg and a thickened, retracted anterior mitral leaflet, causing severe regurgitation. The left ventricular ejection fraction was 66%. Our multidisciplinary heart team decided to explant the prosthetic aortic valve and perform surgical aortic and mitral valve replacements.

Before median sternotomy, the right common femoral artery and vein, and the right internal jugular vein were cannulated, and cardiopulmonary bypass was instituted. After aortic cross-clamping, antegrade cold crystalloid cardioplegia (modified del Nido solution) was administered. We performed an extended transseptal atriotomy followed by oblique aortotomy. We used the ‘lasso technique’ to create a secure dissection plane between the intima and the sutureless aortic prosthesis, which has a self-expanding stent incorporated into the aortic wall. The procedure details were described in our previous report [3]. In summary, a 2–0 polyester purse-string suture was passed along the edge of the frame and secured using a tourniquet to collapse the prosthesis, creating a secure dissection plane. Dissection was then carried out using the tourniquet as a handle to control the prosthesis (Additional file 1: Video 1). Previously [3], we used two tourniquets to explant a transcatheter aortic valve prosthesis but in the present case, only one tourniquet was sufficient. Adhesions were more severe at the annulus than aortic wall. During debridement of the residual calcification at the aortic annulus, we noticed some intimal denudation, and we repaired it with an autologous pericardial patch using 5–0 polypropylene running suture.

The native mitral valve was excised and a 25 mm Hancock II (Medtronic, Minneapolis, MN, USA) prosthetic mitral valve was implanted using 13 everting buttress sutures of 2–0 polyester with pledgets. Subsequently, an Avalus (Medtronic) 19 mm prosthetic aortic valve was implanted using 12 non-everting sutures of 2–0 polyester with pledgets. All sutures were tied using Cor-Knot (LSI Solutions, NY, USA) automated titanium fasteners. Cardiopulmonary bypass was weaned off smoothly. Cardiopulmonary bypass and aorta cross-clamping times were 146 and 108 min, respectively. Postoperative transthoracic echocardiography showed no aortic regurgitation and a mean transvalvular pressure gradient of 12 mm Hg, with normal ventricular function. However, indexed effective orifice area of the prosthetic aortic valve was 0.64 cm2/m2 indicating severe patient-prosthesis mismatch. The mechanical ventilation time was 6 h, and the patient was discharged after 7 days without complications.

This study was approved by the Institutional Review Board (IRB) and ethics committee of the Asan Medical Center (approval number, 2022–1096; approval date, 10 August 2022). The requirement for informed consent was waived because of the retrospective nature of the study design. All relevant data are included in the manuscript and its supporting files.