Purpose: Uniportal video-assisted thoracoscopic surgery (UVATS) has been increasingly adopted for lung cancer management. This study aims to compare the perioperative and oncological outcomes of UVATS versus multiportal VATS (MVATS).

Methods: A comprehensive search was conducted on electronic databases. Perioperative outcomes evaluated were postoperative complications, conversion to open thoracotomy, and visual analog scale (VAS) scores on postoperative days 1 (POD1) and 3 (POD3). The oncological outcomes assessed were total lymph nodes retrieved. Individual patient time-to-event data were estimated from published Kaplan–Meier curves.

Results: The analysis demonstrated that UVATS was associated with significantly lower postoperative complications (relative risk [RR]: 0.76; 95% confidence interval [CI]: 1.64–0.91; p = 0.002), lower VAS scores on POD1(MD: –0.44; 95% CI: –0.70, –0.17; p = 0.001) and POD3 (MD: 0.76; 95% CI: –1.17, –0.36; p <0.001) compared to MVATS. Although UVATS had a lower conversion rate, this difference was not statistically significant (RR: 0.63; 95% CI: 0.33–1.18; p = 0.15). MVATS retrieved a higher number of lymph nodes, but this difference was also not statistically significant (MD: 0.6; 95% CI: –1.39, 0.12, p = 0.1). The overall survival probability at 96 months was slightly higher in the MVATS group (82.49%) compared to the UVATS group (75.89%), with a p-value of 0.5. Disease-free survival was comparable between the groups (75.43% UVATS and 74.74% MVATS, p = 0.59).

Conclusion: UVATS demonstrated favorable perioperative outcomes and comparable oncological efficacy to MVATS in the management of lobectomy and segmentectomy for lung cancer.

Purpose: This study aims to determine the outcomes of maintaining antegrade pulmonary blood flow (APBF) during the bidirectional cavopulmonary shunt (BCPS) procedure in patients with single ventricle physiology undergoing staged palliative surgeries.

Methods: A systematic search of electronic databases was conducted and focused on studies comparing pulsatile BCPS (with APBF) with non-pulsatile BCPS (without APBF). Outcomes were categorized into early (post-BCPS) and late (pre-Fontan). Data were analyzed using Mantel-Haenszel random effects model with odds ratios (ORs) and mean differences (MDs) with 95% confidence intervals (CIs). The study protocol was registered in the PROSPERO (CRD42024586369).

Results: A total of 17 studies with 2504 patients were included. There was no significant difference in 30-day mortality (OR 1.11, 95% CI: 0.61–2.04, p = 0.73), but pulsatile BCPS led to a higher rate of prolonged chest drainage (OR 2.45, 95% CI: 1.43–4.20, p <0.001). Pulsatile BCPS resulted in significantly higher SaO₂ in both post-BCPS (MD 3.33%, 95% CI: 2.70–3.97, p <0.001) and pre-Fontan (MD 2.91%, 95% CI: 2.51–3.31, p <0.001). The Nakata index was also higher in the pulsatile group (MD 30.67, 95% CI: 16.68–44.65, p <0.001).

Conclusions: Pulsatile BCPS can optimize pre-Fontan hemodynamics by improving oxygenation and pulmonary artery development. However, the increased risk of prolonged chest drainage requires careful patient selection and monitoring.

Purpose: Endovascular aneurysm repair (EVAR) is widely used to treat abdominal aortic aneurysms (AAAs), but mid-term survival remains a concern. This study aims to develop a machine learning-based random forest model to predict 3-year survival after EVAR.

Methods: A random forest model was trained using data from 176 EVAR patients, of whom 169 patients were retained for analysis, incorporating 23 preoperative and perioperative variables. Model performance was evaluated using 5-fold cross-validation.

Results: The model achieved an area under the receiver-operating characteristic curve (AUC) of 0.91, with an accuracy of 81.1%, a sensitivity of 81.6%, a specificity of 80.9%, and an F1 score of 0.66. Feature importance analysis identified poor nutritional status (geriatric nutritional risk index <101.4), compromised immunity (neutrophil-to-lymphocyte ratio >3.19), chronic kidney disease (CKD), octogenarian status, chronic obstructive pulmonary disease (COPD), small aneurysm size, and statin use as the top predictors of 3-year mortality. The average values of the AUC, accuracy, sensitivity, specificity, and F1 score across the 5-folds were 0.76 ± 0.10, 73.9 ± 5.8%, 60.4 ± 1.9%, 77.8 ± 0.7%, and 0.59 ± 0.17, indicating consistent performance across different data subsets.

Conclusions: The random forest model effectively predicts 3-year survival after EVAR, indicating key factors such as poor nutritional status, compromised immunity, CKD, octogenarian status, COPD, small aneurysm size, and statin use.

Purpose: This study aimed to summarize 8-year clinical outcomes for patients who underwent transcatheter aortic valve replacement (TAVR) with the J-Valve system and evaluate the long-term durability and hemodynamic performance of the valve.

Methods: Between July 2014 and June 2015, 21 patients underwent transapical TAVR with the J-Valve system. Systematic clinical and echocardiographic follow-up was conducted on 18 patients for up to 8 years.

Results: Eight years post-TAVR with the J-Valve system, the all-cause mortality rate was 16.7%, with no prosthesis failures or thrombosis. Moderate to severe valve deterioration was observed in 50% of patients with aortic stenosis (AS), whereas no such deterioration was noted in patients with pure aortic regurgitation (PAR). At 8 years following TAVR, the effective orifice area measured 2.27 ± 0.50 cm² in patients with PAR and 1.35 ± 0.38 cm² in those with AS. Additionally, patients with AS exhibited a mean pressure gradient of 17.90 ± 10.61 mmHg. Over 8 years, PAR patients experienced a significant reduction in left ventricular end-diastolic diameter from 61.50 ± 2.08 mm to 48.67 ± 7.23 mm (p < 0.001), whereas AS patients showed no significant change.

Conclusion: The J-Valve system demonstrates favorable long-term outcomes in TAVR, with excellent durability and hemodynamic performance in PAR patients.

Purpose: Carotid endarterectomy (CEA) and carotid artery stenting (CAS) are both well-established treatments for carotid artery stenosis. We analyzed real-world data from the Korean National Health Insurance Service (NHIS) database to compare the clinical outcomes.

Methods: This retrospective cohort study included patients with carotid artery stenosis registered in the NHIS from 2008 to 2018. Patients who underwent either treatment were divided into CEA or CAS groups and subjected to 1:4 propensity score matching.

Results: The study cohort included 1521 CEA and 6768 CAS patients. In symptomatic patients, the stroke rate within 1 month was lower in the CAS group (hazard ratio [HR], 0.61). However, the incidence of cardiovascular disease (CVD) death was higher in the CAS group at 1 month, 1 year, and during the total follow-up (HRs, 4.18, 2.43, and 1.50). There were no significant differences in outcomes between asymptomatic patients in the 2 groups.

Conclusion: The periprocedural stroke risk was higher in symptomatic carotid stenosis patients who underwent CEA, but mortality was higher in those who received CAS, both in the short and long term. In asymptomatic patients, however, the incidence of major adverse cardiovascular events and mortality was similar between the 2 groups.

Purpose: Lung torsion is a rare postoperative complication of pulmonary resection caused by lobe displacement. This condition leads to bronchial or pulmonary vascular kinking, which results in airway obstruction or blood flow impairment. In particular, middle lobe torsion is commonly observed after right upper lobectomy. However, the conditions under which it occurs remain unclear. This study aimed to identify the risk factors for middle lobe torsion following right upper lobectomy.

Methods: From November 2012 to December 2024, 127 patients underwent thoracoscopic right upper lobectomy at our institution. Four patients diagnosed with postoperative middle lobe torsion were classified into the torsion group. These patients were retrospectively compared with those without torsion.

Results: Simultaneous partial middle lobe resection and the number of staples used for interlobar fissure formation between the upper and middle lobes were significantly associated with lung torsion. The cutoff value for the number of staples used in the upper-middle fissure formation was 4, demonstrating fair accuracy.

Conclusions: The risk factors for middle lobe torsion after thoracoscopic right upper lobectomy were simultaneous partial resection of the middle lobe and the number of staples used for interlobar fissure formation between the upper and middle lobes.

Purpose: To report our experience with robotic-assisted redo coronary artery bypass grafting (CABG).

Methods: This single-center retrospective study included patients undergoing robotic-assisted redo CABG between 2016 and 2023. Patient demographics and operative outcomes were compared with those of initial robotic-assisted CABG procedures performed during the same period.

Results: There were 12 patients undergoing robotic-assisted redo CABG, with a median age of 73 years. Compared to initial CABG patients (n = 1415), the Society of Thoracic Surgeons scores were significantly higher (median: 0.90 vs. 7.05, p <0.001) in the redo group. Six patients had de novo internal mammary artery (IMA) to left anterior descending (LAD) bypass, 4 had redo LAD bypass, and 2 had non-LAD bypass. Among the 10 patients with LAD bypass, 4 also underwent hybrid percutaneous coronary intervention. While operating room time (5.4 vs. 7.4 hours, p <0.001), postoperative lengths of stay (4.0 vs. 5.5 days, p = 0.02) and the need for blood transfusion (15% vs. 42%, p = 0.02) were significantly greater in the redo group compared to the initial group, there were no conversions to sternotomy, unplanned revascularization, or in-hospital mortality in the redo patients.

Conclusion: Robotic-assisted redo CABG demonstrated promising operative outcomes in appropriately selected patients despite the higher-risk cohort.

Purpose: The objective of this study was to evaluate the safety and efficacy of catheter-directed thrombolysis (CDT) and mechanical aspiration (MA) for acute pulmonary embolism (PE).

Methods: From February 2022 to October 2024, the clinical data of patients with high- and intermediate-risk PE who received endovascular therapy were retrospectively reviewed. Patients were categorized based on the treatment strategy.

Results: Fifty-eight consecutive patients were identified. CDT was initiated in 29 patients, while the remaining 29 received MA treatment. The time of thrombolysis and the dosage of urokinase were both lower in the MA group (P <0.05). No differences were found in cardiac biomarkers after 48 hours, perioperative bleeding events, heart/valve injury, and mortality. The total cost of the MA group was much higher compared to CDT alone. The MA group showed better improvement in right ventricular (RV) function with a higher reduction in the right ventricular-to-left ventricular ratio (0.55 ± 0.46 vs. 0.13 ± 0.53, P = 0.017). No differences were found in the reduction of the CT obstruction index.

Conclusion: CDT and MA seem to have similar outcomes for patients with acute high- and intermediate-risk PE. MA is more effective in improving RV function with less thrombolysis time and fewer thrombolytics.

Purpose: This study aimed to compare the efficacy and safety of liposomal bupivacaine (Lip-BPVC) versus standard bupivacaine (BPVC) for superficial parasternal intercostal plane block in patients undergoing elective coronary artery bypass grafting (CABG) via median sternotomy.

Methods: A total of 82 adult patients were randomly assigned to the BPVC group (n = 41) or the Lip-BPVC group (n = 41).

Results: The Lip-BPVC group demonstrated significantly lower pain scores at all postinjection time points compared to the BPVC group with fewer opioid analgesics. Lip-BPVC demonstrated an initial heightened inflammatory response postoperatively compared to standard BPVC, indicated by significantly lower levels of pro-inflammatory markers at 24 and 48 hours postinjection with BPVC. However, by 72 hours, inflammatory markers did not differ significantly between Lip-BPVC and BPVC groups. No significant differences were observed between the groups in terms of surgery duration, extubation time, intensive care unit and hospital length of stay, or incidence of postoperative nausea and vomiting.

Conclusions: Lip-BPVC initially increased inflammatory markers postoperatively, but levels were comparable to BPVC by 72 hours. It provided superior pain control and reduced opioid use compared to standard BPVC in CABG patients, with similar safety and recovery outcomes.

Purpose: The application of wedge resection in thoracoscopic surgery is becoming more and more widely prevalent. However, achieving precise intraoperative positioning of the pulmonary nodules still poses challenges. This study proposed a method for surface positioning using a computed tomography (CT) simulation positioning system in the radiation physics room.

Methods: After screening patients, the level of nodules was located under the CT simulation positioning system, and the pleural projection point of the nodule and the closest surface puncture point from this point to the body surface were determined by the laser positioning system. During the operation, a needle was inserted at a predetermined angle at the puncture point, leaving a pinhole in the visceral pleura. Finally, the distance between the true pleural projection point of the nodule and the pinhole was measured on the specimen.

Results: The success rate of our positioning method was 97.2%. The average distance between the puncture pinhole location and the actual pleural projection point of the nodule was 8.1 mm. No related complications occurred during the perioperative period.

Conclusion: The new method of preoperative surface positioning and intraoperative lung positioning through puncture has a high success rate, good positioning accuracy, and good safety, which is worthy of clinical application.

Purpose: There are limited data on outcomes of combined Maze and mitral valve procedures beyond 10 years. This study analyzed the efficacy of this operation.

Methods: Between June 2004 and December 2022, 406 patients underwent mitral surgery concomitant with Maze procedure were evaluated. Rhythm outcomes, predictors of recurrence, and survival were assessed.

Results: The median follow-up period was 100 months. Rheumatic disease was present in 58%. Mitral valve repair was performed in 57.1%. Freedom from atrial fibrillation (AF) at 5, 10, and 15 years was 82.5%, 70.8%, and 52.7%, respectively. Overall survival rates were not different between patients in sinus rhythm (SR) and those who remained in AF (p = 0.172). However, patients in SR experienced fewer neurological complication (p = 0.001). Predictors of AF recurrence included preoperative AF duration (p = 0.005), left atrial diameter (LAD) >50 mm (p <0.001), concomitant tricuspid valve surgery (p = 0.049), and the presence of AF on postoperative day 7 (p <0.001). Factors influencing survival were age >60 years (p <0.001) and a postoperative left ventricular ejection fraction <40% (p <0.001).

Conclusions: The combined Maze and mitral valve surgery provides significant benefits in managing AF with mitral disease. Predictors of recurrence included AF duration, LAD size >50 mm, associated tricuspid valve disease, and AF on day 7. SR patients had fewer neurological complications.

Purpose: Our primary concern was the risk of overtreating elderly patients with endovascular aneurysm repair (EVAR) for abdominal aortic aneurysm. We investigated the association between age at the time of EVAR and all-cause mortality in Japan’s aging population by stratifying patients into age groups.

Methods: Data from 175 patients who underwent elective EVAR from 2012 to 2016 were analyzed. Patients were categorized into 3 age groups: <75 years, 75–84 years, and ≥85 years, based on Japan’s healthy life expectancy and average life expectancy. Survival rates and risk factors for mortality were assessed across these patient groups.

Results: Among 175 patients, 3- and 5-year survival rates were significantly lower in elderly patients, with rates of 74.6% and 64.2% for those aged 75–84 years and 51.9% and 39.7% for those aged ≥85 years. Multivariate analysis identified age ≥85 years, chronic kidney disease, chronic obstructive pulmonary disease, and active cancer as independent adverse predictors of all-cause mortality, whereas obesity was identified as an independent protective predictor.

Conclusions: Adjusting guidelines to incorporate not only comorbidities but also age could optimize outcomes and healthcare resource allocation by prioritizing EVAR for patients most likely to benefit in Japan’s super-aging society.

Purpose: Owing to the time-sensitive nature of myocardial ischemia, challenging clinical scenarios should be considered in patients with type A acute aortic dissection (AAAD) complicated by coronary malperfusion. In clinical settings, the diagnosis and reperfusion strategies for coronary malperfusion often depend on institutional resources. This study evaluated early surgical outcomes in such patients, focusing on transportation type and clinical management.

Methods: We retrospectively reviewed 70 patients who underwent emergency surgery for AAAD with coronary malperfusion, excluding those with cardiac tamponade on arrival, between 1997 and February 2024. Patients were divided into 2 groups based on transportation: direct transfer and referral.

Results: Overall, in-hospital mortality was 27%, with only 1 of 9 patients surviving with preoperative peripheral extracorporeal membrane oxygenation (ECMO). Mortality and morbidity did not significantly differ between groups. Univariate analysis identified left coronary artery involvement and preoperative hemodynamic instability as significant risk factors. Additionally, preoperative diagnostic-only coronary angiography (CAG) with unsuccessful reperfusion was a potential risk factor (P = 0.06).

Conclusions: Regardless of transportation type, preoperative peripheral ECMO itself could not be a definitive solution in AAAD patients with coronary malperfusion. Also, patients who underwent preoperative CAG with unsuccessful reperfusion might be fatal, especially with suspected left coronary artery involvement.

Purpose: In totally endoscopic off-pump left atrial appendage (LAA) closure and surgical ablation, securing the operative field is sometimes difficult in some patients because of a narrow working space caused by an elevated diaphragm or ventricles. In this study, we aimed to investigate the effectiveness of a method that facilitates securing the operative field using an artificial pneumothorax.

Methods: We analyzed 71 consecutive patients who underwent totally endoscopic off-pump LAA closure and bilateral pulmonary vein isolation. The factors contributing to the reduction in operative time were examined. The patients were divided into the following 2 groups according to whether or not an artificial pneumothorax was used: Group C comprised 24 patients without an artificial pneumothorax and Group A comprised 47 patients with an artificial pneumothorax.

Results: There were no hospital deaths or major complications. The operative time was significantly shorter in Group A (108 ± 26 minutes) than in Group C (198 ± 77 minutes) (p <0.0001).

Conclusions: In totally endoscopic off-pump LAA closure and surgical ablation, an artificial pneumothorax may be useful in reducing the operative time.

Purpose: The underlying mechanism why segmentectomy has demonstrated the non-inferiority to lobectomy in several randomized trials remains unclear. Computed tomography (CT)-measured pulmonary artery (PA) enlargement reflects PA pressure and predicts the prognosis of certain respiratory diseases. We compared the preoperative and postoperative PA diameter to the ascending aorta diameter (PA/A) ratio, investigating its impact on right ventricular function in lung resection.

Methods: This retrospective study was conducted in patients with lower-lobe lung tumors who underwent anatomical lung resection between 2017 and 2022. The PA diameter at the bifurcation and the ascending aorta diameter at the same CT image slice were measured preoperatively and postoperatively. We calculated the enlargement of PA/A ratio (PA/A change) and compared lobectomy and segmentectomy.

Results: This analysis included 279 patients (235 with lobectomy and 44 with segmentectomy). The PA/A change was significantly greater in patients with lobectomy than segmentectomy (104% vs. 102%, P = 0.02). In the multivariable analysis, airflow obstruction (yes, P = 0.04) and the type of surgery (segmentectomy, P = 0.04) were independent prognostic factors for PA/A change.

Conclusions: The PA/A change was greater in lobectomy than in segmentectomy. This change could reflect a burden on right ventricular function after lobectomy.

Purpose: We aimed to elucidate the efficacy of conventional cisplatin-based adjuvant chemotherapy for patients with lung cancers harboring epidermal growth factor receptor (EGFR) mutation.

Methods: This retrospective cohort study included 110 patients (EGFR mutation group: n = 51; EGFR wild-type group: n = 59) receiving cisplatin-based adjuvant chemotherapy following complete resection of non-small-cell non-squamous-cell lung cancer (2010–2021). Clinicopathological characteristics, recurrence-free survival (RFS), and overall survival (OS) were investigated.

Results: The pStage distribution was not statistically different. The EGFR mutation group was characterized by more advanced pN, papillary predominance, and presence of micropapillary components, whereas the EGFR wild-type group exhibited more advanced pT and solid predominant patterns. The median RFS was significantly worse in the EGFR mutation group (23.0 vs. 76.1 months, p = 0.017). Nevertheless, the median OS was not significantly different (85.6 months vs. not reached, p = 0.151). Multivariable analysis demonstrated that EGFR mutation and lymphatic invasion were significant risk factors in RFS; however, no independent factors were identified in OS.

Conclusions: Cisplatin-based adjuvant chemotherapy might be less effective in patients with EGFR-mutated lung cancer. The style of progression and histological pattern related with EGFR mutation may be associated with the efficacy of adjuvant chemotherapy and poor RFS.

The malignancy risk has increased following improvements in the long-term survival rates after liver transplantation. Reports show a 23.4-fold increase in the risk of de novo esophageal cancer after liver transplantation compared to the general population. We report the case of a 47-year-old female diagnosed with early esophageal cancer after liver transplantation. Endoscopic submucosal dissection was performed; however, due to it being a noncurative resection, additional treatment was required. Total robot-assisted minimally invasive esophagectomy (RAMIE) was performed using a robot for thoracic and abdominal procedures. Although extensive adhesions were observed after liver transplantation, precise surgery using the robot did not damage any vital organs, such as the graft blood vessels. The patient was discharged without postoperative complications. Total RAMIE for esophageal cancer after liver transplantation is a feasible and safe option following careful evaluation of the patient’s condition, and expands the possibilities of successful complex posttransplant surgeries through robotic precision.

Bronchogenic cysts (BCs) are often incidental findings during imaging and can cause compressive symptoms depending on their location and size. Infections of mediastinal BCs are serious complications that can lead to life-threatening mediastinitis. The impact of severe acute respiratory syndrome coronavirus 2 on BCs remains largely undocumented. We present a unique case of a purulent-inflammatory mediastinal BC complicated by sepsis in the context of a Coronavirus Disease 2019 infection. The Coronavirus Disease 2019 infection may result in a bacterial superinfection of the BC. However, the transmission path requires further investigation. For the surgical excision, we opted for a two-step surgical approach: thoracoscopic incision and drainage in the acute setting, followed by elective thoracotomy and resection of the BC. We confirm the safety and favorable outcome of this approach.

Left atrial mitral valve chorda (LAMVC) is a rare congenital cardiac anomaly. The abnormal tissue band, like a mitral valve chorda, is attached to the left atrial wall on one side and mostly to the mitral valve leaflet on the other side and the band sometimes disturbs the mitral leaflet motion, followed by mitral regurgitation (MR). We encountered a case with a LAMVC which originated from a papillary muscle and attached to the posterior mitral annulus over the posterior leaflet and caused MR due to restricted mitral leaflet motion.

A 68-year-old woman was diagnosed with clinical T3N1M0 middle thoracic esophageal cancer. Preoperative three-dimensional computed tomography indicated a right superior posterior pulmonary vein (RSPPV) anomaly, which ran behind the right intermediate bronchus. The patient underwent thoracoscopic esophagectomy with mediastinal lymph node (LN) dissection. Before we began the dissection of the right subcarinal LN, we administered indocyanine green intravenously to confirm the running position of the anomalous RSPPV, and we were able to ascertain its placement accurately with correct recognition of the difference between the blood vessels and surrounding tissue. Although the patient had LN metastasis adjacent to this anomalous vessel and the dissection procedure was tough due to tightly adhesion, intraoperative fluorescent imaging enabled us to perform the dissection without any superfluous vascular injury. Intraoperative fluorescent imaging is very useful in such cases, providing accurate intraoperative information on the location of the anomaly and facilitating safer surgery.

This preclinical study in a porcine model of recurrent regurgitation following tricuspid valvuloplasty aims to confirm the feasibility and safety of a novel transjugular tricuspid valve (TV) replacement device and to optimize the implantation procedure prior to first-in-human study. The novel device was implanted via a transjugular approach in a large white pig model (n = 2). No perivalvular leakage (PVL) or central tricuspid regurgitation (TR) was observed on post-operative echocardiography. The mean transvalvular gradient at 3 months follow-up was 1.69 ± 0.7 mmHg with mild central TR but no PVL. There was no right ventricular outflow tract obstruction, III atrioventricular block, device malposition, pericardial effusion, coronary artery compression, or myocardial infarction. This technique may be a promising option for patients after TV valvuloplasty and is ideal for high-risk patients undergoing open-heart surgery.

Minimally invasive direct coronary artery bypass grafting for the left anterior descending artery is a well-established technique; however, harvesting the internal thoracic artery is challenging, particularly with endoscopic approaches. In this study, 12 patients underwent internal thoracic artery harvesting using a three-dimensional endoscope with a three-port system (one incision plus two ports). Working space was established by elevating the chest wall upward using hooks anchored at the main incision site. To enhance operability, the positions of the camera and instruments were strategically adjusted within the existing ports, obviating the need for additional access points. All patients achieved graft patency. No complications, such as internal thoracic artery injury, were observed, and no patient required conversion into median sternotomy. This approach minimizes invasiveness while maintaining effectiveness, allowing for adequate dissection of the internal thoracic artery without necessitating expansion of the existing surgical setup.

Mitral annular calcifications have been known to increase complexity during mitral valve replacement (MVR). Standard procedure requires decalcification followed by reconstruction of the mitral annulus prior to placing the prosthesis. While this is the ideal technique, it is not feasible in every patient due to the associated risks. The mere attempt at valve replacement without proper annular decalcification has been associated with a high incidence of periprosthetic leak which complicates the postoperative course and has been associated with increased morbidity and mortality. With the advances in transcatheter therapy, postoperative periprosthetic regurgitation can be managed with devices and primary transcatheter valve implantation could be alternative to standard valve replacement; however, these alternate strategies are not without its own limitations and drawbacks. In the current report, we present a novel strategy to be used in a select group of patients with severe but non-circumferential annular calcifications to prevent/minimize periprosthetic regurgitation during MVR. This involves placing a patch over the posteriorly located calcium bar, thus minimizing tension on the posterior suture line and contain any periprosthetic regurgitation if to develop. This modification has been performed in a total of nine cases with acceptable early results.