A supra-annular malposition of the Perceval S sutureless aortic valve: the ‘χ-movement’ removal technique and subsequent reimplantation

Abstract

The Perceval S sutureless valve prosthesis has recently been introduced as a new biological aortic valve prosthesis, but a specific learning curve is required, as for every cardiac surgical centre dealing with a new technique. After the removal of the stenotic valve, the prosthetic valve is correctly positioned within the mildly decalcified aortic annulus. When a supra-annular malposition occurs, due to an excessively rapid release of the prosthesis in the aorta or incomplete annular visualization, the Perceval S valve can safely be removed even after balloon dilation. The procedure performed is a ‘χ-movement’ with the aid of anatomical forceps. If the prosthesis does not show any malformation after the procedure, it can be reimplanted in the correct intra-annular position.

INTRODUCTION

The recent use of a new sutureless bioprostheses is gaining widespread clinical application, requiring a more exacting evaluation than ever before in order to choose more suitable models and materials. This entails two major challenges: (i) a learning curve is unavoidable when new surgical techniques are implemented and depends on the resources available to invest in training; and (ii) benefits should be weighed against risks prior to the selection of a given model.

Here, we describe in detail the procedure to be performed when a Perceval S aortic valve (Sorin Group, Saluggia, Italy) is malpositioned, with the removal and subsequent reimplantation of the undamaged prosthesis.

TECHNIQUE

The Perceval S sutureless aortic valve can be implanted via a complete or partial sternotomy or right anterior thoracotomy with cardiopulmonary bypass, depending on the surgeon's preference and expertise. In our case (Supplementary Video 1), the procedure was performed through a complete sternotomy because the patient had undergone previous cardiac surgery (2005) for aortic valve replacement with a Sorin Soprano bioprosthesis (18-mm) with subsequent degeneration and severe aortic stenosis.

Supplementary Video 1: An excessively rapid release of the Perceval S bioprosthesis in the supra-annular aortic position. Inspection of the device and the stent traction. The ‘χ-movement’ technique and valve removal. Reimplantation of the same bioprosthetic valve in the correct intra-annular position.

As in all procedures that are not performed through the transcatheter approach, the Perceval S valve implantation is preceded by the removal of the diseased, native or prosthetic valve. In this case, we removed the bioprosthesis previously implanted and, in order to ensure the correct positioning of the prosthesis, three polypropylene guiding sutures were placed beneath the leaflet insertion line as a reference for an accurate alignment of the valve. The aortic annulus was without lesions. After the release of the prosthesis, the Prolene guiding sutures were removed. A dedicated balloon was then inserted in the valve and expanded for 30 s at a pressure of 4 atm, as recommended by the manufacturer. The valve was maintained in a continuous flux of sterile water at 37°C to allow the extension and the intra-aortic wall fixing of the super elastic metal alloy stent. As we know, different stented and stentless models do not have an equivalent diameter inside. Keeping this fact in mind, although the old valve was given as ‘18-mm’, we verified this by going across the annulus with the Perceval's sizer, and a 21-mm sizer did it; consequently, we implanted a 23-mm valve. As is shown in the video, the collapsed prosthetic valve is deployed into the aortic root. During the valve release, probably due to an abnormal angulation of the delivery system, the valve prosthesis could be implanted in a supra-annular position. After final post-dilation with a balloon catheter, if a valve malposition occurs, it is usually recognized by the observation of the annulus under the opened prosthetic leaflets with the aid of anatomical forceps. The visualization of the aortic annulus and the guiding sutures under the leaflets is suggestive of prosthetic malposition.

In such an occurrence, the prosthesis must be rinsed with cold water because of the specific features of the nitinol stent. Then the procedure is performed holding the superior portion of the stent at two opposite points and dragging them to the centre at the same time, forming a ‘χ’ (Fig. 1). Using the ‘χ-movement’, the prosthesis is easily removed, whereas the use of other procedures, even with a stronger impact, does not have the same rate of success (Supplementary Video 1). After removal, the prosthesis is rinsed with warm water and then checked for damages or malformations. If intact, the valve is re-collapsed and repositioned in the correct intra-annular location (Supplementary Video 1).

Figure 1:

Description of the ‘χ-movement’ with the aid of two anatomical forceps.

DISCUSSION

The recent introduction of sutureless bioprostheses for aortic valve replacement has raised a debate on the clinical usefulness of these devices. At the Techno College of the 25th EACTS Annual Meeting in Lisbon, Martens gave an interesting lecture entitled ‘Sutureless valves: useless gadget or facilitating technology?’. The goal of this article is not to answer this question but to describe the experience of our centre (81 sutureless bioprosthesis implantation procedures) that allowed us to go well beyond the learning curve and identify the potential advantages of this approach. The technique described here shows the clear advantages of the Perceval sutureless prosthesis over other devices that do not guarantee the same adaptability during valve removal. In addition, the re-use of the same undamaged prosthesis offers two more advantages: a shorter cross-clamping time and a substantial reduction in the procedure-related costs per patient.

Previous reports have already highlighted the safety of this prosthesis and the reduction of the overall surgical time [1, 2]. In our centre, we are mostly interested in the suitability of this device in different surgical conditions [3, 4]. In this case, we report the malposition of the prosthesis probably due to a too fast valve release or incorrect visualization of the nadir of the guiding sutures. Before the valve's release, we suggest controlling it under the holder in the efflux tract: if the guiding suture is not seen, the aortic annulus is not seen then too and one is able to implant the Perceval in the correct intra-annular position. We describe not only the easy removal technique using the ‘χ movement’, which allows a high success rate compared with other techniques, but also the stability and versatility of this prosthesis following balloon post-dilation.

In conclusion, in our experience, the Perceval S aortic valve bioprosthesis is safe and easy to use. In the case of a supra-annular malposition, the valve can be quickly removed using the ‘χ movement’ and, if undamaged, repositioned.

Supplementary material

Supplementary material is available at ICVTS online.

Conflict of Interest: None declared.