Introduction
Bicuspid aortic valve (BAV) is a common congenital heart condition affecting approximately 0.5% of the population.1 In its pure form, a Type 0 BAV results from two aortic cusps without any raphes whereas BAV Type 2 occurs with two raphes. Type 1 BAV is the most common form with one raphe and is particularly associated with fusion of the right and left cusps.2 The need for surgery of the aortic valve and/or aorta is increased in patients with BAV, with one study showing a 27% incidence of a surgical event over a 20-year period.3 Additionally, up to one third of patients undergoing aortic valve replacement may also require aortic root surgery.4
The advent of sutureless and rapid-deployment valves has facilitated surgery for patients who would otherwise not be a surgical candidate due to frailty or prolonged surgical procedures. Sutureless valves (Perceval Sorin (LivaNova group) Sutureless Aortic Heart Valve (Perceval) and 3f Enable (ATS Medical) Aortic Bioprosthesis (3f Enable)) consist of three biological pericardial leaflets mounted within a self-expanding Nitinol frame.5 Upon expansion, these prostheses are stabilized in place by radial outward force without relying on permanent suturing to the patient’s aortic annulus.6 The Perceval valve is inserted using a transverse aortotomy with temporary guiding sutures at the nadir of each sinus in the annulus and passed through the eyelets of each valve.7 Commissural traction sutures are removed following visual confirmation of correct valve placement, and the balloon is then inflated at 4 atm for 30 seconds.8 Following deflation, the catheter is removed. The 3f Enable valve is also inserted using a transverse aortotomy, although its implantation is slightly different. When inserting the 3f Enable valve, its commissural tabs are attached to the aorta (near the level of the native aortic annulus) and spaced at 120-degree intervals. The commissural tabs are fixated using three mattress sutures with pledgets, two lateral sutures, and one horizontal suture once the inner holder has been removed.9 It should be noted that this device was discontinued in May 2015 for safety concerns. The rapid-deployment valve (Intuity (Edwards Lifesciences) valve (Intuity)) consists of three biological pericardial leaflets anchored to a balloon-expandable, stainless steel cloth-covered frame that is incorporated into the valve inflow.10 For Intuity rapid deployment valve insertion, a hockey stick aortotomy should be performed and extend obliquely across the sinotubular junction to the middle of the noncoronary sinus. Similar to the Perceval sutureless valve insertion, the native leaflets should be excised and debridement of the annulus should be conducted. Three equidistant guiding sutures should be placed at the nadir of each coronary cusp, and exit 2-3 mm above the annulus. Using the guiding sutures, the valve should be parachuted using the associated delivery system perpendicularly into the annulus. Once the valve has been determined to be correctly positioned, the balloon is inflated to 4.5-5 atm and maintained for 10 seconds prior to deflating it. Following deflation, the delivery system is removed and the three guiding sutures are cut and serially tied.
BAV has traditionally been considered a relative contraindication for the use of sutureless and rapid-deployment prostheses due to anatomic concerns surrounding valve implantation. These concerns were primarily due to how uneven alignment of the two cusps and aortic root asymmetry in BAV may result in paraprosthetic leak.11 In recent years, numerous studies have attempted to expand sutureless and rapid-deployment valves to the BAV patient population. The purpose of this scoping review is to describe the outcomes and complication rates of patients BAV undergoing aortic valve replacement with the Perceval sutureless prosthesis, 3f Enable sutureless prosthesis, or Edwards Intuity rapid-deployment prosthesis.