The Degenerated Sutureless Valve in Full Root Prosthesis

Abstract

Background

The availability of sutureless prostheses has provided another tool for the treatment of degenerated aortic bioprostheses, mostly those used for aortic root replacement, such as stentless porcine or homograft. However, also sutureless-in-root prosthesis can undergo degeneration, presenting a further surgical challenge.

Case Summary

We present 2 patients facing a degenerated M size Perceval prosthesis, previously implanted in a degenerated Freestyle valve. Both patients received a ballon-expandable valve. One, the younger patient, underwent open-heart surgery for sutureless explantation and then implantation of a new device. The other underwent transcatheter valve-in-valve procedure.

Discussion

The treatment of a degenerated sutureless-in-root necessitates re-intervention, with the balloon-expandable devices emerging as a highly promising option also in open-heart setting.

Take-Home Messages

Degeneration of Perceval-in-Freestyle bioprostheses can be effectively managed. The choice between surgical and transcatheter implantation should be individualized, considering patient characteristics and anatomical suitability.

Visual Summary

The Freestyle aortic root prosthesis (Medtronic), a stentless porcine bioprosthesis introduced to the market in 1997, has proven to be a valuable option for aortic valve and aortic root replacement in aged patients. It can be an alternative to autograft/homograft in complex root anatomy, or it can be useful in young or active patients who have contraindications or unwilling to undergo long-term anticoagulation therapy. The Freestyle valve is derived from an intact porcine aortic root designed for total root replacement and treated with a proprietary anticalcification protocol. However, despite promising early and mid-term results, structural aortic valve deterioration remains a notable long-term limitation, mainly related to progressive leaflet calcification and/or tear, which may ultimately necessitate reintervention.

In the past, the standard of care for bioprosthetic aortic valve failure has been redo surgery. Redo surgery is associated with increased risk of morbidity and mortality of 3% to 7%, rising to 30% in high-risk patients, especially in a context of acute aortic endocarditis.^1,2 Nowadays, transcatheter aortic valve implantation (TAVI) has become the treatment of choice not only for native aortic valve stenosis in patients over 70 years of age but also for high surgical risk patients with prior cardiac interventions.

In case of risky TAVI (ie, related to possible coronary obstruction), an established treatment for degenerated Freestyle valves has been also the implantation of sutureless aortic bioprostheses such as Perceval (Corcym) or rapid-deployment valves like Intuity (Edwards Lifesciences).³ The first one is bioprosthesis composed of bovine pericardial tissue mounted on a self-expanding nitinol stent, it does not need anchoring sutures, and it reduces surgical times which is particularly beneficial in the context of a reoperation.⁴

In 2013, our center was the first to describe using a sutureless Perceval valve to manage degeneration of a Freestyle root bioprosthesis, introducing a new surgical valve-in-valve (ViV) concept avoiding redo Bentall.⁵ However, as with its predecessors, the new valve-in-root is also susceptible to long-term degeneration.⁶

As a result of modern trend of patient's preferences, it is no longer rare to encounter a patient who underwent their first major cardiac surgery for a biological root replacement at 50, experienced a degeneration of that prosthesis around age 65, and now, at 75, faces the failure of their second valve. This evolving clinical scenario was first emphasized by early reports, including that of Tomai and colleagues, who described such reoperations as the “Matryoshka procedure.”⁷

The current strategy for these cases involves a ViV procedure using a transcatheter heart valve, a balloon-expandable valve, which is usually preferred over taller self-expandable valve to reduce the risk of coronary obstruction. However, its design makes it appealing also for open-heart implantation. Furthermore, the latter approach has the advantage of allowing the surgeon to explant the old valve. This permits the sizing and implantation of a larger prosthesis, thereby reducing the risk of patient-prosthesis mismatch (PPM) and consequently also the rate of degeneration. A larger valve offers better blood flow dynamics and is associated with increased long-term durability.

Patient 1

The first case is about a young male (70 Kg, 165 cm, body surface area 1.8 m²) with severe aortic insufficiency and aneurysmal dilation, stemming from a bicuspid aortic valve. In 2011, at the age of 30, the patient underwent a Bentall procedure with implantation of a Freestyle n.25 valve and an Intervascular 26 vascular prosthesis via sternotomy, and during the same intervention, a correction of a thoracic aortic coarctation was also performed through thoracotomy.

However, the patient's course was complicated by infective endocarditis in 2020, which resulted in severe postendocarditis aortic insufficiency due to bioprosthetic degeneration, ultimately necessitating a redo operation. During this second surgery, a Perceval Plus M bioprosthesis was implanted. The Perceval valve, known for its sutureless design, was chosen, likely to facilitate the redo procedure in a previously operated field. The postoperative course of this redo procedure was uneventful.

Unfortunately, the patient's relief was short. In May 2025, he presented with dyspnea, and echocardiographic findings were alarming, revealing early and significant degeneration of the Perceval bioprosthesis. The hemodynamic parameters were critically deranged: a peak gradient of 71 mm Hg, a mean transaortic gradient of 48 mm Hg, and a severely reduced aortic valve area of 0.8 cm² (Figure 1A).

Figure 1.

Patient 1, Echographic Assessment

Echocardiographic gradients in Patient 1 before (A) and after (B) the procedure, demonstrating a marked reduction following intervention.

Given the rapid deterioration of the Perceval valve, a TAVI protocol computed tomography (CT) scan was performed to meticulously assess the anatomy and plan for further intervention (Video 1). The decision to perform an open-heart implantation of a Sapien 3 Ultra 26-mm valve after removal of the degenerated Perceval prosthesis was driven by the high risk of coronary obstruction, as the height of the left coronary ostium was <10 mm with a tightened sinus-tubular junction (Figure 2). This approach allowed direct visualization and safe management of the complex anatomy. The surgical procedure was performed through a median resternotomy, with cannulation of the ascending aorta and bicaval cannulation under mild hypothermia (34 °C). Myocardial protection was achieved using retrograde Buckberg cardioplegia. The choice of bicaval cannulation was made to allow greater cardiac mobility in case dissection of the Freestyle root was required. The explantation of the Perceval valve proved to be unexpectedly straightforward (Video 2). The heavily calcified Freestyle valve from the initial Bentall procedure had created a rigid “shell” resulting in an unusual anatomical configuration. This prevented the Perceval valve from fully integrating into the surrounding tissue. As a consequence, the valve remained only loosely attached, which greatly facilitated its removal (Figure 3). The new prosthesis was mounted on the conventional transfemoral release system (Edwards Commander) and was already preloaded on the balloon. A mark with a sterile marker had been made on the prosthesis prior to crimping, and commissural orientation was attempted during catheter insertion into the left ventricular outflow tract. Considering that the valve shortens from below during deployment, the implantation depth was determined under visual guidance, and the valve was released at the level of the inferior margin of the coronary buttons. Deployment under direct vision ensured control of patency and unobstructed blood flow access to the coronary ostia. At intraoperative echocardiography, the implant was deemed satisfactory, although the valve settled 1 to 2 mm below the intended position. A 1-month follow-up echocardiogram revealed no PPM, no leaks with mean gradients of 12 mm Hg (Figure 1B).

Figure 2.

Patient 1, CT Scan

Patient 1 preoperative computed tomography scan with multiplanar reconstruction and coronary occlusion risk assessment: (A) right coronary; (B) left coronary.

Figure 3.

Perceval Valve Degeneration After Removal

Patient 2

The patient's initial cardiac event occurred in 2004, at the age of 53, when he developed destructive endocarditis affecting both the aortic annulus and root. This necessitated surgical intervention, and a Freestyle 25 aortic root bioprosthesis was implanted.

Eight years later, in 2012, at the age of 61, the patient presented with a recurrence of endocarditis. During this reoperation, a Mitroflow n21 bioprosthesis was implanted within the previously placed Freestyle conduit. Intraoperatively, extensive calcification of the aortic root was noted, which precluded the performance of the redo Bentall procedure.

By 2020, at 69 years of age, the Mitroflow bioprosthesis had degenerated. The patient underwent a third surgical intervention, where the degenerated Mitroflow valve was removed, and a Perceval size M sutureless bioprosthesis was implanted.

In 2025, at 74 years of age (71 kg, 173 cm, body surface area 1.85 m²), the Perceval bioprosthesis showed signs of severe degeneration, characterized by mean/maximum transaortic gradients of 53/84 mm Hg and an aortic valve area of 0.7 cm² (Figure 4A). Considering the patient's advanced age and a recent bleeding complication, an additional conventional cardiothoracic surgery was deemed to carry an extremely high risk. A TAVI protocol CT scan was performed to assess anatomical suitability (Video 3). The CT scan showed a low risk of coronary obstruction, with height >10 mm for both coronary arteries (Figure 5). In June 2025, the patient successfully underwent a ViV TAVI procedure. Due to the presence of the Perceval valve nitinol stent, prophylactic protection of the left main coronary artery with a guidewire was used. ViV TAVI with Sapien Ultra n23 valve was then deployed without complication (Video 4). Immediate postimplantation angiography showed unclear images between the left main and the newly implanted prosthesis (Figure 6); therefore, intravascular ultrasound was performed, confirming the absence of significant stenosis and ruling out the need for coronary stenting. Transvalvular gradients could not be measured by catheterization due to interference of the pigtail with a valve cusp, causing aortic regurgitation, which resolved upon withdrawal of the pigtail from the left ventricle.

Figure 4.

Patient 2, Echographic Assessment

Echocardiographic gradients in Patient 2 before (A) and after (B) the procedure, highlighting the hemodynamic improvement achieved postoperatively.

Figure 5.

Patient 2, CT Scan

Patient 2 preoperative CT scan with multiplanar reconstruction and coronary occlusion risk assessment: (A) right coronary; (B) left coronary.

Figure 6.

Angiography With Left Main Protection

RCA = right coronary artery.

A 1-month follow-up echocardiogram revealed persistent PPM, with maximum/mean gradients of 47/24 mm Hg (Figure 4B). The case was discussed in a multidisciplinary Heart Team, which weighed the risks and benefits of the transcatheter procedure, the high risk of conventional surgical intervention (Society of Thoracic Surgeons Score: 9.12%), the patient's comorbidities, ultimately considering the risk of a PPM as the lesser harm.

Discussion

These 2 intricate case reports showed the evolving landscape of managing complex aortic valve pathologies, particularly in patients with a history of recurrent endocarditis and multiple prior surgeries. The cases underscore persistent challenges related to bioprosthetic durability in demanding anatomical environments in the context of lifetime management.

A striking commonality between patient 1 and patient 2 is the reduced durability of their bioprosthetic valves following previous surgical aortic root and aortic valve replacement. Patient 1, initially receiving a Bentall procedure with a Freestyle conduit for a bicuspid aortic aneurysm, subsequently experienced degeneration of a Perceval Plus M bioprosthesis within 5 years. Similarly, patient 2, with a history of destructive endocarditis and a Freestyle aortic root bioprosthesis, saw his Mitroflow and later Perceval valves degenerate within relatively short periods. This accelerated deterioration, particularly in the context of extensive aortic root calcification or prior prosthetic material, raises critical questions about factors influencing bioprosthetic longevity. In addition, previous research has indicated that prior endocarditis can negatively impact the durability of subsequent bioprosthetic valves, possibly due to persistent inflammation or altered tissue properties.⁸

The treatment pathways of these 2 patients exemplify the ongoing shift in managing degenerated surgical bioprostheses. Patient 2's progression to a ViV TAVI due to prohibitive surgical risk, including advanced age and recent bleeding, reflects the growing acceptance and efficacy of transcatheter approaches in this challenging cohort. ViV TAVI offers a less-invasive alternative, avoiding the morbidity and mortality associated with repeat open-heart surgery.⁹ However, the residual PPM observed in patient 2 post-ViV TAVI highlights a known limitation of this procedure, particularly when implanting a new valve within a relatively small existing prosthesis without a possibility of stent expansion due to the calcified root wall. This can lead to persistent elevated gradients and potentially impact long-term outcomes.¹⁰

Conversely, patient 1's management involved an open surgical explantation of the degenerated Perceval valve and subsequent open Sapien3 Ultra valve implantation, even after considering TAVI. This decision underscores that despite the advancements in transcatheter technologies, complex anatomical scenarios, the advantage for complete removal of previous prosthetic material, or concerns about future reinterventions may still favor a surgical approach. The ease of Perceval explantation due to the “shell” effect was an unexpected benefit in patient 1's case, demonstrating how prior surgical constructs can uniquely influence subsequent reoperations. Moreover, coronary patency is reassuringly ensured in the surgical setting, as the bioprosthesis is released under direct vision rather than under indirect angiographic guidance. The excellent postoperative outcomes in patient 1, with no PPM and low gradients, further validate this individualized surgical strategy.

These cases collectively emphasize the need for a multidisciplinary heart team approach to carefully weigh the risks and benefits of surgical vs transcatheter reintervention, considering patient-specific factors such as age, comorbidities, prior surgical history, and the detailed anatomy of the aortic root and existing prostheses. As the population of patients with multiple prior valve surgeries grows, understanding the unique challenges of re-reoperations and optimizing treatment strategies will become even more critical.

Funding Support and Author Disclosures

Drs Villa, Messina, Cirillo, and Troise are “clinical proctors” for Corcym. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.

Take-Home Messages

• •Recurrent endocarditis or complex and diminutive aortic root anatomy significantly impact bioprosthetic durability, often leading to accelerated degeneration and challenging reinterventions.
• •A multidisciplinary heart team approach is crucial for individualized decision-making, carefully balancing the benefits of less-invasive transcatheter options with the potential benefit of open surgery in complex redo cases.
• •While valve-in-valve transcatheter aortic valve implantation offers a vital less-invasive solution for high-risk patients, the potential for persistent patient-prosthesis mismatch should be considered in these anatomically challenging scenarios.

Appendix

Video 1

Contrast-Enhanced Computed Tomography Angiography of Patient 1, Performed for Preprocedural Planning and Anatomical Assessment

Video 2

Patient 1: Intraprocedural Echocardiography

Procedural sequence in patient 1 showing explantation of the sutureless prosthesis and subsequent implantation of the Sapien 3 Ultra transcatheter heart valve under direct surgical visualization, with the final echocardiographic result.

Video 3

Contrast-Enhanced Computed Tomography Angiography of Patient 2, Illustrating Anatomical Features Relevant for Preprocedural Planning

Video 4

Transcatheter Valve-in-Valve Procedure in Patient 2, With Preprocedural and Postprocedural Echocardiographic Assessment and Intraprocedural Angiographic