 radiograph, while the other two leaflets showed calcification. The differential calcification of the leaflets of the same CEP valve is thought to be related to the different bovine origin of the component tissues of the valve. The imbalance of calcification in the three leaflets can cause imbalance of the tension between these leaflets, increasing the risk of leaflet tear \[[@B6],[@B7]\]. In our patient, the tear was noted in the leaflet that showed no calcification, while the other two leaflets showed calcification. An interesting report on the Mosaic valve, which is of single porcine origin, indicates excellent durability of the valve in the mitral position, with no evidence of SVD at 10 years \[[@B8]\]. If this is true, the different pattern of SVD of the CEP valve, especially the occurrence of the tear, may be attributable to its different origin. On the other hand, the quality of each component could also be different even in the single porcine valve, hence further investigation is necessary.

In conclusion, in Japanese patients with a high life expectancy, SVD of an implanted bioprosthetic valve can occur in patients undergoing the valve surgery even after 70 years of age. While it would be desirable to implant bioprosthetic valves for elderly patients to avoid the risk of major bleeding, reoperation may become necessary in patients living long after the surgery. We have described the first case of a patient who developed SVD and explantation of a CEP valve, 16 years after it was implanted, in a patient who was over 70 years of age at the time of the surgery.

Competing interests
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The authors declare that they have no competing interests.

Authors\' contributions
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HI performed the procedure. KS, TH, and YK participated in the procedure. All authors read and approved the final manuscript.


INTRODUCTION {#S1}
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Compulsive sexual behavior (CSB) has been proposed to have two primary components: 1) a pattern of abnormally frequent paraphilic (e.g., fetish