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 time1ā4. 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-Sā rate of adverse events (notably renal insufficiency and
blood transfusion) are similar or lower to that of conventional
bioprothesis1ā3, while mortality and paravalvular
leak rates are lower than in TAVI3,9ā12.
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.