Use of Sutureless and Rapid Deployment Prostheses in Challenging Reoperations

A rapid deployment valve option for failing Medtronic Freestyle full root: a single centre experience

BACKGROUND

There are several high-risk treatment options for valve failure of a biological full root replacement. When tailoring the best treatment option for the patient, implantation of a rapid deployment valve (RDV) should be considered.

CASE PRESENTATION

Six patients presented with aortic regurgitation in a full root Freestyle bioprosthesis. Three had a history of valve endocarditis, while the remaining had non-infectious structural valve deterioration with leaflet and commissural tears. All patients were treated with a rapid deployment EDWARDS INTUITY Elite valve. Follow-up was complete for all patients. Postoperative echocardiography showed well-functioning valve prostheses with no paravalvular leaks and acceptable pressure gradients. Echocardiographic follow-up demonstrated excellent pressure gradients and a considerable decrease in the left ventricular mass index and left ventricular end-diastolic dimensions. Follow-up cardiac CT showed no signs of coronary obstruction or other pathology. During a median follow-up of 30 months neither biological valve failure, nor any events within the composite endpoint of major adverse cardiac and cerebrovascular events occurred.

CONCLUSIONS

This case series presents the EDWARDS INTUITY valve as a good treatment option in patients with failing Freestyle roots.

Sutureless and Rapid Deployment Prosthesis in Redo-Bentall Endocarditis

Aortic valve replacement (AVR) in a patient with a bio-Bentall conduit can be very challenging, especially if there was a previous endocarditis process for significant morbidity and mortality. We report a case of sutureless AVR in an old patient with a bio-Bentall conduit (Carpentier-Edwards Perimount Magna Ease 25 aortic valve and Hemashield 30 aortic conduit), who developed an endocarditis on aortic prosthesis valve. We believe that sutureless AVR is the best option for redo-operation in older patients with a high surgical risk because it allows for easy rapid deployment implantation, avoids anchoring sutures on a fragile aortic anulus, and reduces cardiopulmonary and aortic cross-clamp times. In this setting, it should be considered as a safe and valid alternative not only to traditional prosthesis but also in selected cases to transcatheter valve-in-valve solutions.

Single-center real-world data and technical considerations from 100 consecutive patients treated with the Perceval aortic bioprosthesis

Objectives

Although the Perceval sutureless aortic valve bioprosthesis presents a feasible alternative to conventional aortic valve prostheses, the extent of its applicability with respect to technical considerations for a real-world patient collective is still under debate.

Methods

One hundred patients received the Perceval prosthesis [males: 59; age: 72.5 (7.3-79) years] between December 2015 and February 2023 [EuroSCORE II: 2.8 (1.7-5.4)] for an aortic valve replacement (AVR), with additional concomitant procedures, for underlying severe aortic valve stenosis [n = 93 (93)], endocarditis [n = 5 (5)], and redo AVR [n = 7 (7)] including a prior surgical AVR [n = 4 (4)] and a failed transcatheter aortic valve implantation [n = 3 (3)]. Surgery was conducted primarily by median sternotomy [n = 71 (71)] and, alternatively, by the upper hemisternotomy approach [n = 29 (29)].

Results

Over a median follow-up time of 36.5 (16.5-53) months, eight patients (8%) underwent postoperative pacemaker implantation, with five (5%) due to high-grade atrioventricular block, while nine patients experienced a stroke (9%). The median values of maximum and mean gradients across all valve sizes were 22 (18-27.5) mmHg and 10 (13-18) mmHg, respectively. Two patients (2%) had moderate and one (1%) had severe paravalvular leakage, with the latter presenting the only case of underlying valve migration and induced redo AVR with valve explantation 2 days following initial surgery. Thirty-day mortality (and overall mortality) was 5% and 26%, respectively.

Conclusion

The implantation of the Perceval bioprosthesis is feasible for a variety of indications, with excellent hemodynamic results and low complication rates in a real-world high-risk patient collective.

Successful Implantation of Rapid Deployment Aortic Valve after TAVR Explantation

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has become widely used in recent years, However, there is also an increasing need for removal of TAVR valves due to prosthetic valve dysfunction (PVD) and the development of infective endocarditis. Surgical aortic valve replacement (AVR) for these patients is risky due to the original patient background and anatomic conditions. Intuity rapid deployment aortic valve (Edwards Lifesciences, Irvine, CA) replacement would be useful for such high risk patients to prevent longer cardiac arrest time and obtain good hemodynamic results. However, there are few reports which present Intuity valve replacement after TAVR explantation. Herein, We report two cases in which we have achieved good hemodynamics with shorter cardiac arrest times by using a rapid deployment valve after TAVR explantation.

CASE PRESENTATION

We present 2 cases of successful implantation of the Intuity rapid deployment valve after TAVR explantation. The 84- and 88-year-old female patients had previously received TAVR for severe aortic stenosis with SAPIEN XT (Edwards Lifesciences, Irvine, CA) and developed PVD during follow-up. The TAVR valve was removed carefully, then an Intuity valve was implanted with cardiac arrest times of 69 and 41 min. Both patients had good echocardiographic results with effective orifice area of 2.0 cm2 and 1.2 cm2 and mean trans-aortic plessure gradient of 9 mmHg and 15 mmHg respectively without aortic regurgitation. They were discharged without major complications.

CONCLUSIONS

Surgical AVR using a rapid deployment valve is a useful alternative to sutured AVR after TAVR valve explantation. It allows for shorter cardiac arrest times and better postoperative hemodynamics without major complication.

Sutureless Biological Aortic Valve Replacement (Su-AVR) in Redo operations: a retrospective real-world experience report of clinical and echocardiographic outcomes

OBJECTIVE

This retrospective study aimed to compare the outcomes of sutureless aortic valve replacement (su-AVR) and conventional bioprosthetic sutured AVR (cAVR) in high-risk patients undergoing redo surgery.

METHODS

A total of 79 patients who underwent redo AVR between 2014 and 2021 were included in the study. Of these, 27 patients underwent su-AVR and 52 underwent cAVR. Patient characteristics and clinical outcomes were analysed using multivariate regression and Kaplan Meier survival test.

RESULTS

The groups were similar in terms of age, gender, left ventricular function, and number of previous sternotomies. In cases of isolated AVR, su-AVR had significantly lower cross clamp times than cAVR (71 vs. 86 min, p = 0.03). Postoperatively, 4 cAVR patients required pacemaker compared to zero patients in the su-AVR group. There were no significant differences between the two groups in terms of postoperative complications, intrahospital stay (median 9 days, IQR 7-20), or in-hospital mortality (1 su-AVR; 2 cAVR). The long-term survival rate was similar between the su-AVR (90%) and cAVR (92%) groups (log rank p = 0.8). The transvalvular gradients at follow-up were not affected by the type of valve used, regardless of the valve size (coef 2.68, 95%CI -3.14-8.50, p = 0.36).

CONCLUSION

The study suggests that su-AVR is a feasible and safe alternative to cAVR in high-risk patients undergoing redo surgery. The use of su-AVR offers comparable outcomes to cAVR, with reduced cross clamp times and a lower incidence of postoperative pacemaker requirement in isolated AVR cases. The results of this study contribute to the growing body of evidence supporting the use of su-AVR in high-risk patients, highlighting its feasibility and safety in redo surgeries.

Sutureless Aortic Valve Prosthesis in Redo Procedures: Single-Center Experience

Background and Objectives: Sutureless aortic valve prostheses have presented favorable hemodynamic performance while facilitating minimally invasive access approaches. As the population ages, the number of patients at risk for aortic valve reoperation constantly increases. The aim of the present study is to present our single-center experience in sutureless aortic valve replacement (SU-AVR) in reoperations. Materials and Methods: The data of 18 consecutive patients who underwent SU-AVR in a reoperation between May 2020 and January 2023 were retrospectively analyzed. Results: The mean age of the patients was 67.9 ± 11.1 years; patients showed a moderate-risk profile with a median logistic EuroSCORE II of 7.8 (IQR of 3.8-32.0) %. The implantation of the Perceval S prosthesis was technically successful in all patients. The mean cardiopulmonary bypass time was 103.3 ± 50.0 min, and the cross-clamp time was 69.1 ± 38.8 min. No patients required a permanent pacemaker implantation. The postoperative gradient was 7.3 ± 2.4 mmHg, and no cases of paravalvular leakage were observed. There was one case of intraprocedural death, while the thirty-day mortality was 11%. Conclusions: Sutureless bioprosthetic valves tend to simplify the surgical procedure of a redo AVR. By maximizing the effective orifice area, sutureless valves may present an important advantage, being a safe and effective alternative not only to traditional surgical prostheses but also to transcatheter valve-in-valve approaches in select cases.

Replacement of a Calcified Aortic Valve in a Porcine Aortic Root with the Perceval Sutureless Bioprosthesis

We report a 79-year-old patient who had aortic valve replacement (AVR) using a porcine aortic root. Due to degeneration of the porcine aortic valve, he required reoperation during which a heavily calcified porcine root and aortic annulus prevented insertion of any traditional bioprosthesis. AVR was achieved using a sutureless bioprosthesis, combined with mitral valve replacement. The present case confirms the feasibility and advantages of using sutureless valve implantation in complex and high-risk redo procedures.

Long-term durability of a Perceval aortic valve implanted inside a calcified homograft root in a patient with Klippel-Trenaunay-Weber syndrome

BACKGROUND AND AIMS

Perceval valves are sutureless surgical bioprostheses designed for the aortic position. We report on the use of a Perceval sutureless valve for redo aortic valve replacement inside a heavily calcified homograft root in a patient with Klippel-Trenaunay-Weber syndrome.

MATERIALS AND METHODS

Anonymized patient case data was extracted from hospital electronic records.

RESULTS

A now 62-year-old woman with Klippel-Trenaunay-Weber syndrome underwent homograft aortic root replacement for congenital aortic valve dysplasia when she was 39 years old. She re-presented in 2012 with severe symptomatic aortic regurgitation through the homograft root. Computed tomography scanning revealed a heavily calcified homograft root. In order to avoid a high-risk redo root replacement or a challenging sutured aortic valve replacement, she underwent Perceval sutureless aortic valve implantation. As of 9.5 years following Perceval implantation, the bioprosthetic valve function remains excellent, with no transvalvular regurgitation seen.

DISCUSSION AND CONCLUSION

This case reveals the value of Perceval valve implantation in redo surgery inside a hostile calcified homograft aortic root. Furthermore, we highlight the long-term durability of the Perceval sutureless bioprosthesis.