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• W2401766727 abstract "Aortic root replacement with porcine xenograft is a valuable treatment option in acute aortic dissection, but conduits are often prone to degeneration. Reoperation is still associated with high operative mortality, and it usually requires root removal and repetition of the Bentall procedure, or a less radical option limited to valve replacement. We describe two cases of Freestyle root degeneration in patients with chronic aortic dissection, in whom we performed a valve-in-valve procedure with the Perceval S prosthesis (Sorin Group, Saluggia, Italy). Aortic root replacement with porcine xenograft is a valuable treatment option in acute aortic dissection, but conduits are often prone to degeneration. Reoperation is still associated with high operative mortality, and it usually requires root removal and repetition of the Bentall procedure, or a less radical option limited to valve replacement. We describe two cases of Freestyle root degeneration in patients with chronic aortic dissection, in whom we performed a valve-in-valve procedure with the Perceval S prosthesis (Sorin Group, Saluggia, Italy). Drs Glauber and Ferrarini disclose a financial relationship with Sorin.The Freestyle aortic bioprosthesis (Medtronic, Inc, Minneapolis, MN) is a stentless porcine root, often used for full root replacement in aortic valve and root diseases, such as acute aortic dissection. Freedom from structural valve deterioration at 15 years is 75%, with reported failures that can range from regurgitation (leaflet rupture or graft dilatation) to stenosis (leaflet calcification) [1Mohammadi S. Tchana-Sato V. Kalavrouziotis D. et al.Long-term clinical and echocardiographic follow-up of the Freestyle stentless aortic bioprosthesis.Circulation. 2012; 126: S198-204Crossref PubMed Scopus (44) Google Scholar]. Reoperation is a demanding procedure associated with high mortality [2Borger M.A. Prasongsukarn K. Armstrong S. Feindel C.M. David T.E. Stentless aortic valve reoperations: a surgical challenge.Ann Thorac Surg. 2007; 84: 737-743Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar], which has traditionally been tackled in two ways: implantation of a stented valve within the root or a radical Bentall repetition [2Borger M.A. Prasongsukarn K. Armstrong S. Feindel C.M. David T.E. Stentless aortic valve reoperations: a surgical challenge.Ann Thorac Surg. 2007; 84: 737-743Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar, 3Finch J. Roussin I. Pepper J. Failing stentless aortic valves: redo aortic root replacement or valve in a valve?.Eur J Cardiothorac Surg. 2013; 43: 495-504Crossref PubMed Scopus (21) Google Scholar]. More recently, transcatheter aortic valve implantation (TAVI) has emerged as a new alternative treatment option [4Walther T. Falk V. Dewey T. et al.Valve in-a-valve concept for transcatheter minimally invasive repeat xenograft implantation.J Am Coll Cardiol. 2007; 50: 56-60Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar, 5Dvir D. Webb J. Brecker S. et al.Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves. Results from the global valve-in-valve registry.Circulation. 2012; 126: 2335-2344Crossref PubMed Scopus (466) Google Scholar]. We report two complex cases of Freestyle failure in patients with chronic aortic dissection treated with a valve-in-valve (V-in-V) procedure with the sutureless Perceval S prosthesis (Sorin Group, Saluggia, Italy). Drs Glauber and Ferrarini disclose a financial relationship with Sorin. The first patient was a 72-year-old woman previously treated in 2011 for type A acute aortic dissection (AAD) with aortic root and ascending aorta replacement with a Freestyle No. 25 root and an InterGard No. 30 Dacron graft (Maquet Cardiovascular, La Ciotat, France). Eleven years later, the patient experienced acute heart failure. Echocardiography revealed severe aortic regurgitation caused by cusp rupture, moderate mitral regurgitation with annular dilatation, and reduction of left ventricle ejection fraction (LVEF) (45%). Her logistic EuroScore was 27.3%. We scheduled the patient for an aortic valve replacement (AVR) with a V-in-V procedure with Perceval S, and mitral annuloplasty. A repeated sternotomy was performed. The mitral annulus was dilated and corrected with a Sorin Memo 3D No. 30 ring (Sorin Group). Then, transverse aortotomy was carried out at the level of the previously implanted prosthesis, the annulus was measured, and a Perceval size L valve was chosen. Then, three double-needle 4-0 Prolene sutures were placed at the nadir of the valve sinuses, corresponding to the Freestyle annulus: these sutures served as a guide for positioning the prosthesis. The collapsed valve was slid down over the guide sutures inside the valve annulus. After the release of the prosthesis and subsequent balloon expansion, the valve was maintained in a continuous flux of sterile water at 37°C to allow the extension and the intraaortic wall fixing of the Nitinol stent. The cardiopulmonary bypass (CPB) and aortic cross-clamp times were 100 and 62 minutes, respectively. Postprocedural transesophageal echocardiography (TEE) showed no paravalvular leakage of the prosthesis, with a mean transaortic gradient of 11 mm Hg, and no residual mitral regurgitation. The ventilation time was 6 hours, and the intensive care unit (ICU) stay was 4 days because of pulmonary dysfunction. The patient was discharged 9 days after the operation. At the 7-month follow-up visit, the patient was asymptomatic without aortic sutureless prosthesis malfunction, and any paravalvular leakage was detected at echocardiography. The mean pressure gradient remained stable relative to the discharge value (10 mm Hg). The second patient was a 83-year-old female who had undergone an emergency operation for type A AAD in 2000, with implantation of a Freestyle Medtronic root No. 27 and a Dacron InterGard No. 26 graft. In 2013 she was admitted to our institution for progressive dyspnea (New York Heart Association functional class III)] and evidence of aortic valve regurgitation caused by cusp rupture. Preoperative TEE revealed rupture of the noncoronary cusp. A 6-cm pseudoaneurysm originating at the level of the noncoronary sinus was detected on computed tomography scanning (Fig 1). Her logistic EuroScore was 38.5%. A second sternotomy was performed, and very strong adhesions were observed, which prevented aortic clamping. Therefore, CPB was established with femorofemoral cannulation, the core temperature was allow to drift to 26°C, and the operation performed while the patient was in circulatory arrest with selective anterograde bilateral cerebral perfusion. Surgical examination revealed perforation of the noncoronary cusp and confirmed the presence of a pseudoaneurysm originating from a tear in the aortic root, parallel to the noncoronary cusp. After excision of the xenograft cusps, the pseudoaneurysm was repaired with a Dacron patch. Then a Perceval size L prosthesis was implanted as described above. The CPB and circulatory arrest times were 223 and 52 minutes, respectively. The ventilation time was 13 hours, and the ICU stay was 1 day. The patient was discharged 9 days after the operation with no major adverse events, no paravalvular leakage of the aortic prosthesis, and a mean gradient of 10 mm Hg, detected at echocardiography. At the 1-year follow-up visit, the patient was in good clinical condition, and the prosthesis showed good hemodynamic performance. Reoperative AVR can be usually performed with a low risk of mortality [6Jaussaud N. Gariboldi V. Giorgi R. et al.Risk of reoperation for aortic bioprosthesis dysfunction.J Heart Valve Dis. 2009; 18: 256-261PubMed Google Scholar]. However, some situations can be challenging, such as reoperations after stentless AVR; historically, stentless prostheses failure has necessitated an open revision operation, typically with replacement of the entire aortic root. In the review by Borger and colleagues [2Borger M.A. Prasongsukarn K. Armstrong S. Feindel C.M. David T.E. Stentless aortic valve reoperations: a surgical challenge.Ann Thorac Surg. 2007; 84: 737-743Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar] review of reoperations for failing Freestyle valves, redo root replacement was necessary in more than half of the patients, with an overall operative mortality of 11%. An alternative is V-in-V implantation, whereby a stented valve is placed within the debrided stentless original [3Finch J. Roussin I. Pepper J. Failing stentless aortic valves: redo aortic root replacement or valve in a valve?.Eur J Cardiothorac Surg. 2013; 43: 495-504Crossref PubMed Scopus (21) Google Scholar]. The V-in-V concept was recently replicated by transcatheter procedures. Currently, TAVI (either transfemoral or transapical) is an emerging alternative for failed bioprostheses, but experience is still limited in stentless valves, and some technical details (eg, absence of radiopaque markers and stents as landing support) make TAVI difficult [4Walther T. Falk V. Dewey T. et al.Valve in-a-valve concept for transcatheter minimally invasive repeat xenograft implantation.J Am Coll Cardiol. 2007; 50: 56-60Abstract Full Text Full Text PDF PubMed Scopus (138) Google Scholar, 5Dvir D. Webb J. Brecker S. et al.Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves. Results from the global valve-in-valve registry.Circulation. 2012; 126: 2335-2344Crossref PubMed Scopus (466) Google Scholar]. We have presented two complex cases of Freestyle failure for leaflet rupture requiring aortic valve replacement. Among the possible surgical options for these high-risk patients, we opted for a sutureless Perceval V-in-V procedure to facilitate the surgical implantation and thus save operative times. This technique allows rapid aortic valve replacement, and it avoids performing a redo Bentall operation with its known morbidity. Compared with stented bioprostheses, the Perceval S can be implanted with reduced cross-clamp time and CPB time, offering good hemodynamics performance with low gradients. In our cases, another treatment option could have been a transapical TAVI procedure, but that was not adopted for many reasons. First, with patient 1, the TAVI option was not possible because the patient also needed correction of mitral valve regurgitation; furthermore, in both cases, the absence of annular calcification or prosthetic stents might also have theoretically increased the risk of prosthesis malposition or migration because of potentially less stable anchorage on the aortic annulus [5Dvir D. Webb J. Brecker S. et al.Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves. Results from the global valve-in-valve registry.Circulation. 2012; 126: 2335-2344Crossref PubMed Scopus (466) Google Scholar]. Finally, ostial left main obstruction, which is reported only rarely during native valve TAVI, seems to be more common during V-in-V procedures in Freedom valves [5Dvir D. Webb J. Brecker S. et al.Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves. Results from the global valve-in-valve registry.Circulation. 2012; 126: 2335-2344Crossref PubMed Scopus (466) Google Scholar]. The Perceval S prosthesis, instead, can be implanted under direct vision of the aortic annulus and allows for proper and straightforward fitting of the bioprosthesis, suggesting a secure valve positioning with no problems of diminished blood flow to the coronary ostia. In conclusion, this case report shows the feasibility of implanting a sutureless aortic valve into a degenerated stentless prosthesis. The net result is avoidance of any paravalvular leakage or coronary obstruction. Last, as reported, it is possible to perform combined procedures." @default.
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• W2401766727 title "Perceval S Valve Solution for Degenerated Freestyle Root in the Presence of Chronic Aortic Dissection" @default.
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