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• W2552686542 abstract "Aortic valve replacement with a Perceval sutureless bioprosthesis is a viable rescue option for a failed aortic stentless prosthesis. However, a dilated sinotubular junction and ascending aorta are reported as a contraindication for this technique. We describe an aortic sutureless valve implantation in a patient with a dilated ascending aorta and small aortic root after Dacron graft replacement of the ascending aorta in a failed aortic stentless bioprosthesis. Aortic valve replacement with a Perceval sutureless bioprosthesis is a viable rescue option for a failed aortic stentless prosthesis. However, a dilated sinotubular junction and ascending aorta are reported as a contraindication for this technique. We describe an aortic sutureless valve implantation in a patient with a dilated ascending aorta and small aortic root after Dacron graft replacement of the ascending aorta in a failed aortic stentless bioprosthesis. The management of a failed stentless aortic prosthesis is a surgical challenge, and the Perceval sutureless bioprostheses (LivaNova PLC, London, UK) could be a viable alternative to a conventional operation or transcatheter aortic valve implantation (TAVI). The Perceval sutureless prosthesis comprises a biological component of bovine pericardium and uses the “memory” of the nitinol metal frame, which deploys and positions the valve with no sutures required. However, an intact sinotubular junction (STJ) and ascending aorta in terms of diameter is a prerequisite for a safe and functional Perceval sutureless bioprosthesis [1Laborde F. Fischlein T. Hakim-Meibodi K. et al.Clinical and haemodynamic outcomes in 658 patients receiving the Perceval sutureless aortic valve: early results from a prospective European multicentre study (the Cavalier Trial).Eur J Cardiothorac Surg. 2016; 49: 978-986Crossref PubMed Scopus (90) Google Scholar, 2Zannis K. Folliguet T. Laborde F. New sutureless aortic valve prosthesis: another tool in less invasive aortic valve replacement.Curr Opin Cardiol. 2012; 27: 125-129Crossref PubMed Scopus (37) Google Scholar]. We report a case of a sutureless valve implantation in a patient with a dilated ascending aorta and small aortic root after Dacron graft replacement of the ascending aorta in a failed aortic stentless bioprosthesis. A 78-year-old man presented with dyspnea 17 years after an aortic valve replacement with a 23-mm Freestyle stentless bioprosthesis (Medtronic, Minneapolis, MN) with use of a subcoronary technique. Echocardiography revealed severe aortic stenosis with a peak gradient of 85 mm Hg and severe aortic insufficiency. There was no significant coronary artery stenosis on angiography; however, the ascending aorta was dilated (Fig 1A). On computed tomography, the distance between the left coronary ostium and the aortic annulus was 10.3 mm (Fig 1B), the ascending aortic diameter was 42 mm at the STJ, and the annulus diameter was 17 mm. Given the limited clearance between the left main ostium and the aortic annulus as well as the latter’s small size, the patient was not considered suitable for TAVI and was scheduled for operation. The redo sternotomy and initiation of cardiopulmonary bypass by conventional central cannulation were uneventful. Myocardial protection was by direct coronary ostial and retrograde cardioplegia. A high transverse aortotomy was performed above the STJ. There was a tear in the right coronary cusp of the Freestyle prosthesis. The valve cusps and fibrotic annular tissue were excised. The aortic root and annulus were severely fibrotic, and the latter was sized to an 18-mm Hegar dilator. A standard aortic root enlargement or modified Bentall procedure was considered high risk, given the severely dense fibrosis and extremely contracted state of the aortic root. A Perceval (size Small) sutureless bioprosthesis was evaluated as a rescue option. However, the commissural posts of the Perceval prosthesis require an intact STJ to allow proper anchoring to the aortic wall [3Folliguet T.A. Laborde F. Zannis K. Ghorayeb G. Haverich A. Shrestha M. Sutureless Perceval aortic valve replacement: results of two European centers.Ann Thorac Surg. 2012; 93: 1483-1488Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar]. The ascending aorta was then excised to correct the large diameter of the STJ and provide a proper anchoring site for the Perceval prosthesis. The proximal anastomosis was then performed at the STJ with a 28-mm Dacron graft. A Perceval valve was deployed in a standard fashion as previously described [3Folliguet T.A. Laborde F. Zannis K. Ghorayeb G. Haverich A. Shrestha M. Sutureless Perceval aortic valve replacement: results of two European centers.Ann Thorac Surg. 2012; 93: 1483-1488Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar] through the open graft (Fig 2), and commissural posts were properly seated at the proximal graft anastomosis level. The graft was then anastomosed to the distal ascending aorta. Weaning from cardiopulmonary bypass was uneventful after 68 and 93 minutes of cross-clamp and bypass time, respectively. Transesophageal echocardiography showed a peak transprosthetic gradient of 12 mm Hg and no paravalvular leak. After an uneventful postoperative course, the patient was discharged after 7 days. At his 6-month follow-up visit, the patient was asymptomatic, with no aortic insufficiency and a peak transprosthetic gradient of 16 mm Hg. The management of a failed stentless aortic prosthesis is challenging. Because of anatomic constraints, the patient described here was not a TAVI candidate. In addition to high postoperative transprosthetic gradients, ostial coronary obstruction can be a catastrophic adverse event after TAVI for a degenerated stentless valve, especially in patients with a subcoronary implantation technique [4Mohammadi S. Baillot R. Voisine P. Mathieu P. Dagenais F. Structural deterioration of the Freestyle aortic valve: mode of presentation and mechanisms.J Thorac Cardiovasc Surg. 2006; 132: 401-406Abstract Full Text Full Text PDF PubMed Scopus (77) Google Scholar]. The propensity for coronary obstruction is related to the spatial geometry of the leaflets and the clearance between the coronary ostia and the annulus [5Bapat V. Davies W. Attia R. et al.Use of balloon expandable transcatheter valves for valve-in-valve implantation in patients with degenerative stentless aortic bioprostheses: technical considerations and results.J Thorac Cardiovasc Surg. 2014; 148: 917-922Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar]. Redo stentless valve operations are complex procedures, frequently requiring aortic root replacement, particularly when the valves are severely adherent to the native aortic wall. Severe fibrosis at the prosthetic annulus, the suture line level, or both, generating high transprosthetic gradients without important calcification, has been described in patients with stentless bioprostheses [6Mohammadi 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-S204Crossref PubMed Scopus (44) Google Scholar]. Trauma to the coronary ostia, aortic wall, annulus, anterior mitral valve leaflet, and membranous septum can occur during reoperation. A modified Bentall procedure may be required, and an interposition graft between the coronary buttons becomes necessary if the coronaries cannot be adequately mobilized or are damaged during dissection. These maneuvers increase the technical complexity of the procedure and prolong cross-clamp and pump times; the reported operative mortality in these cases is as high as 11% [7Borger M.A. Prasongsukarn K. Armstrong S. Feindel C.M. David T.E. Stentless aortic valve reoperations: a surgical challenge.Ann Thorac Surg. 2007; 84: 737-744Abstract Full Text Full Text PDF PubMed Scopus (78) Google Scholar]. In our patient, the conventional implantation of a stented bioprosthesis within the debrided stentless valve was not possible because of the small aortic annulus and the elevated risk of prosthesis–patient mismatch. The absence of a sewing ring makes the Perceval prosthesis effectively stentless, with a greater effective orifice area and excellent hemodynamic performance in patients with small aortic roots [8Villa E. Messina A. Laborde F. et al.Challenge for Perceval: aortic valve replacement with small sutureless valves: a multicenter study.Ann Thorac Surg. 2015; 99: 1248-1254Abstract Full Text Full Text PDF PubMed Scopus (25) Google Scholar]. However, the flared STJ and the dilated ascending aorta would not have provided adequate anchoring for the Perceval prosthesis. An ascending aortic diameter exceeding 4 cm for a large Perceval prosthesis and an STJ/annulus ratio exceeding 1.3 are considered contraindications to this procedure [1Laborde F. Fischlein T. Hakim-Meibodi K. et al.Clinical and haemodynamic outcomes in 658 patients receiving the Perceval sutureless aortic valve: early results from a prospective European multicentre study (the Cavalier Trial).Eur J Cardiothorac Surg. 2016; 49: 978-986Crossref PubMed Scopus (90) Google Scholar, 2Zannis K. Folliguet T. Laborde F. New sutureless aortic valve prosthesis: another tool in less invasive aortic valve replacement.Curr Opin Cardiol. 2012; 27: 125-129Crossref PubMed Scopus (37) Google Scholar]. We addressed this issue by first replacing the ascending aorta and stabilizing the STJ to allow adequate deployment and provide support for the Perceval struts. This modification to make the Perceval sutureless valve a technically feasible option has not been previously described, to our knowledge. The Perceval allows for a rapid aortic valve replacement in a hostile aortic root and preserves both root architecture and the coronary buttons. Densely adherent failed prosthetic valves can be as hostile as calcified roots, and the technical challenges are often underestimated. A dilated ascending aorta or STJ is not necessarily a contraindication to the deployment of a Perceval valve." @default.
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• W2552686542 date "2016-12-01" @default.
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• W2552686542 title "Ascending Aortic Replacement and Sutureless Valve in a Failed Stentless Aortic Prosthesis: A Bailout Option" @default.
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