Use of a sutureless aortic valve in reoperative aortic valve replacement

Abstract

Objectives: Management of degenerated bioprosthetic aortic valves remains a challenge. Valve-in-valve transcatheter aortic valve replacement (AVR) has limited utility in the presence of small annuli/prosthetic valves. Sutureless valves may offer an advantage over traditional redo AVR by maximizing effective orifice area due to their unique design as well as ease of implant.

Methods: Twenty-two patients undergoing redo AVR received a sutureless valve in our institution over the past 5 years. All patients were determined to be poor candidates for valve-in-valve transcatheter AVR due to a combination of small annulus size, low coronary heights, and/or underlying valve characteristics (ie, mechanical valves).

Results: Median time from implant to redo AVR was 8 years. One patient died within 30 days. In the 13 patients who had a 21 mm or smaller valve explanted, 5 small, 7 medium, and 1 large Perceval valves were implanted (all with larger internal diameters than the explanted valve). The average postoperative gradient of the cohort valves was 14.8 mm Hg compared with 38.8 mm Hg preoperatively.

Conclusions: In addition to their ease of use and rapid deployment, sutureless bioprosthetic aortic valves offer significant physiological advantages in patients with degenerated prosthetic aortic valves and small anatomical annuli. It can also simplify the surgical approach to redo AVR following a Bentall procedure. If long-term durability is confirmed, sutureless valves should be considered in a broader population of patients for both redo and primary aortic valve replacement surgery.

Keywords: AI, aortic insufficiency; AVR, aortic valve replacement; PPM, patient–prosthesis mismatch; SAVR; SAVR, surgical aortic valve replacement; STS, Society of Thoracic Surgeons; TAVR; TAVR, transcatheter aortic valve replacement; ViV TAVR; ViV, valve-in-valve; aortic valve; small annulus.

Graphical abstract

ID of the explanted bioprosthetic valve versus the implanted sutureless valve.

Figure 1

A, Size distribution among valves explanted. B, Pre- and postoperative MGs at the first clinic visit after discharge. Patients experienced significant improvement in their hemodynamics after redo valve replacement with a sutureless valve. MG, Mean gradient.

Figure 2

A, Size of valve explanted versus size of sutureless valve implanted. More than one half of patients with a 19- to 21-mm valve explanted had a medium Perceval implanted, and more than half of patients with a 23- to 35-mm explanted had a large Perceval implanted. In general, larger valves were being implanted than were explanted. B, Internal diameter (ID) of the explanted bioprosthetic valve versus the implant valve. Nearly every patient in the cohort had improvement in ID with sutureless placement, thus allowing for improved hemodynamics and a larger scaffold for future valve-in-valve interventions.S, small; M, medium; L, large; XL, extra-large.

Figure 3

Graphical abstract summarizing the hemodynamic outcomes of our patient cohort after Perceval placement during redo AVR. Nearly all patients had a larger internal diameter (ID) valve implanted than what was explanted, which improved their gradients and allows for larger ViV TAVR implants in the future, altogether reducing the risk for PPM. AVR, Aortic valve replacement; EOA, effective orifice area.