Introduction
To date, aortic valve replacement (AVR) is the only curative therapy to treat aortic valve stenosis. Despite the emergence of the transcatheter aortic valve implantation (TAVI) procedure, surgical approach remains the gold standard, especially because it allows for the removal of the diseased valve and decalcification of the annulus, optimizing the annulus size and limiting paravalvular leak occurrence. Over the past decade, sutureless and rapid deployment aortic valves have emerged, offering an alternative to conventional AVR.
The Perceval-S aortic valve (LivaNova, London, UK) is a bioprosthesis based on bovine pericardial leaflets mounted into a flexible, self-expandable nitinol stent. This is the only sutureless valve available on the market and presents several advantages. First, its implantation is rapid, simple and reproducible, which reduces aortic cross-clamping time1–4. Moreover, its collapsible design favors minimally invasive surgical approaches5and facilitates implantation in challenging situations such as redo operations or calcified aortic root3,6,7. It also provides lower transvalvular gradients than conventional stented bioprothesis1,4,8. Recent studies have shown that Perceval-S’ rate of adverse events (notably renal insufficiency and blood transfusion) are similar or lower to that of conventional bioprothesis1–3, while mortality and paravalvular leak rates are lower than in TAVI3,9–12.
Even if the Perceval-S seems to be attractive and has a broad spectrum of use and advantages, its design based on two anchoring sites (the first at the annulus level and the second at the sino-tubular junction [STJ] level) has some pitfalls. Consequently, Perceval-S is contraindicated in case of a ratio between the STJ and the aortic annulus greater than 1.3, aneurysmal dilation or dissection of the ascending aortic wall13. The shape of the annulus is also crucial. In the bicuspid aortic valve (BAV), for example, an ovoid or scalloped annulus (with unequal sub-commissural height) may preclude the valve anchoring and lead to paravalvular leak or valve migration. In this situation, sub-commissural annuloplasty (SCAP) has been sporadically performed in order to circularize the annulus before implanting a Perceval-S14,15. In our surgical experience, we regularly challenge non-circular annulus and the aim of this study is to evaluate if SCAP can safely address this issue.