Conclusions
For a decade, sutureless and rapid deployment aortic valves have
provided a compromise between standard AVR and TAVI by favoring minimal
surgical approach, reducing time procedure and limiting paravalvular
leak. The sutureless Perceval-S aortic valve was designed to be
surgeon-friendly and to make its implantation safe and reproducible. Our
results corroborate its safety as early mortality was low and rate of
implantation success, stroke, pacemaker requirement and post-operative
hemodynamics were similar to those reported in the current
literature19,21.
However, the sutureless feature of the Perceval-S is based on the
specific design of an expandable nitinol stent which needs two anchoring
sites: i) the first one, at the annulus level (inflow ring), ii) and the
second one at the STJ level (outflow ring). These characteristics imply
some procedural caution to avoid implantation pitfalls.
In order to prevent valve migration, the ratio between the aortic
annulus and STJ diameters must be < 1.3, and the size of the
aortic annulus must be < 27mm (according that the Perceval-S
sizes are : S = 19-21mm, M = 21-23mm, L = 23-25mm, XL = 25-27mm).
Moreover, in order to minimize paravalvular leak occurrence, the aortic
annulus must be decalcified enough (but avoiding annulus lesion) to be
flexible enough to be conformed to the valve by the radial force of the
Perceval-S stent. It is also important that annulus has a circular shape
and that the heights of the sub-commissural triangles are neither too
high nor too unequal. Furthermore, the height of the nitinol struts
obligates to slightly modify the surgical technique by performing a
horizontal and higher aortotomy than with sutured prosthetic valves,
which could reduce the accessibility and the exposition of the diseased
aortic valve.
Pre-operative imaging (cardiac-CT or echocardiography) is helpful to
assess the shape and size of the annulus as well as to choose the best
surgical approach22. That allows to estimate the
likelihood of Perceval-S implantation success, but despite of this, some
anatomic features of the aortic annulus (shape, flexibility,
sub-commissural triangle height, calcification, etc…) are
unpredictable before surgery and could hamper Perceval-S implantation.
In such situations, the surgeon should typically substitute a sutured
valve, which is more time consuming and may be challenging, especially
through a minimally invasive approach1–4.
In order to address unexpected anatomical features of the annulus, some
techniques of annuloplasty have been described sporadically to decrease
the risk of implantation failure. In a short series, Ferrari et al.
described how they sneaked a purse string suture of 3-0 polypropylene
all around the aortic annulus before implanting a rapid-deployment
aortic valve (Intuity, Edwards Lifesciences, Irvine, CAL, USA). Before
closing the aorta, the suture was snared to tighten the implanted valve
and minimize both paravalvular leak and valve
migration23. In BAV, Glauber et al. suggested to
reduce the height of the three sub-commissural triangles by a mattress
suture before implanting a Perceval-S valve, if the annulus was overly
scalloped15. In his series of 13 patients with BAV,
Durdu et al. described a similar SCAP technique to ours, used in order
to decrease the height of the sub-commissural triangles and to
circularize the annulus14.
The present study highlights three situations in which SCAP was
particularly helpful: (i) in case of aortic annuli that were slightly
too large or too flexible (ii) in case of elliptic or overly scalloped
aortic annuli (frequent in BAV), (iii) and as a rescue trick in case of
implantation failure. We used 34 SCAPs successfully spread over these
three situations, which permitted to widen the field of use of the
Perceval-S. For example, among the 25 XL-sized valves implanted
(including nine BAV), 14 SCAPs were performed, otherwise we would not
have succeeded to implant it. This may partially explain why we reported
a remarkable proportion of XL-sized valves compared to the current
literature21,24. SCAP also afforded an issue to
address implantation failure in almost one third of patients involved.
We did not notice significant reduction of the effective orifice area
surface, nor an increase of severe mismatch rates in the Group SCAP.
Thus, we can infer that SCAP did not significantly reduce the annulus
size but rather that it improved its congruence with the valve.
Our study presents several limitations. First, this is a monocentric
retrospective study not in intention to treat, as the surgeon decided to
implant a Perceval-S according to his feeling. Moreover, we did not
randomize patients with a group control, in which we would use a sutured
valve instead of SCAP if needed. Finally, our follow up was too short to
evaluate the long-term stability of SCAP, especially in BAVs, which are
known to dilate by time.
This study shows that SCAP is a safe and useful technique that could
improve the success rate of implantation of the Perceval-S sutureless
aortic valve essentially by circularizing the aortic annulus and
reducing the height of sub-commissural triangles. It might be
particularly useful in presence of a BAV or in case of a first
implantation failure, as rescue trick. Larger studies and longer
follow-up periods are necessary.