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An 87-year-old woman underwent AVR (CEP 21 mm) for aortic stenosis at age 73 years. Fourteen years later, she was treated with antibiotics for mediastinal abscess, which showed a tendency to shrink and inflammation improved. At that time, no vegetation or aortic regurgitation was observed. Eight months later, the patient was brought to the emergency room with a complaint of respiratory distress. After close examination, a severe transvalvular leakage was found at the aortic valve position. No vegetation was found. Enhanced chest computed tomography (CT) showed an aneurysm of the left sinus of Valsalva. The diagnosis of healed aortic prosthetic valve endocarditis with an aneurysm of the sinus of Valsalva was made. The CEP valve was removed at surgery, and the valve leaflet corresponding to the right coronary cusp was destroyed. The left sinus of Valsalva was dilated and a Perceval was implanted. The patient was doing well postoperatively, but a pacemaker was implanted due to atrioventricular dissection. Transthoracic echocardiography confirmed that there was no problem with prosthetic valve function at the aortic valve position, and CT showed a reduction of aneurysm of the left sinus of Valsalva. The patient was discharged from the hospital on the 30th postoperative day. Aortic valve replacement with Perceval is effective in high-risk cases of prosthetic valve endocarditis.

Objective Patients with major aortopulmonary collateral arteries (MAPCAs) often require additional surgical or catheter intervention after unifocalization (UF) due to stenosis and poor growth. We hypothesized that the UF design influences vascular growth; assessment was based on the passing route related to the bronchus. Methods We enrolled five patients with pulmonary atresia (PA), ventricular septal defect, and MAPCA who underwent UF and subsequent definitive repair at our institute from 2008–2020. Angiography and computed tomography scans were routinely performed before surgical intervention to clarify pulmonary circulation and the relationships between MAPCAs and the bronchus, which revealed peculiar MAPCAs directed to the pulmonary hilum passing behind the bronchus (defined as retrobronchial MAPCAs; rbMAPCAs). Vascular growth of rbMAPCAs, non-rbMAPCAs, and the native pulmonary artery were assessed using the angiograms before and after repair. Results The angiogram before UF (age; 42 [24–76] days, body weight; 3.2 [2.7–4.2] kg) showed that the diameter of the original unilateral PA, rbMAPCA, and non-rbMAPCA was 19.95 ± 6.65, 20.72 ± 5.36, and 20.29 ± 7.42 mm/m2, respectively (p = 0.917). UF was completed in a single-stage with the placement of modified Blalock–Taussig shunt through median sternotomy at the age of 1.6 (1.0–2.5) months. Angiograms performed 3.0 (1.0–10.0) years after UF completion, demonstrated a smaller rbMAPCA diameter at peri-bronchial region (3.84 ± 2.84 mm/m2) compared to the native unilateral PAs (16.11 ± 5.46 mm/m2, p < 0.0001) and non-rbMAPCA (10.13 ± 4.44 mm/m2, p = 0.0103). Conclusions RbMAPCAs tend to be stenosed at the point where they cross the bronchus and emerge in the middle mediastinum after in situ UF.

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