Invited Commentary

Abstract

Rapid deployment and sutureless valves are being implanted with increasing frequency—particularly in Europe—but specific patient populations for these devices remain to be defined. Theron and colleagues [1Theron A. Gariboldi V. Grisoli D. et al.Rapid deployment of aortic bioprosthesis in elderly patients with small aortic annulus.Ann Thorac Surg. 2016; 101: 1434-1442Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar] have focused on the use of rapid deployment valves in a clinically important subgroup of patients in this issue of The Annals, namely, elderly patients with a small aortic annulus. Severe aortic stenosis is often accompanied by fibrosis and calcification of the aortic root in elderly patients, resulting in an inability to insert an adequately sized prosthesis. Simple implantation of a hemodynamically superior valve would be preferable to annular enlargement procedures in elderly patients. Aortic annular enlargement is associated with prolonged aortic cross-clamp and cardiopulmonary bypass times [2Kulik A. Al-Saigh M. Chan V. et al.Enlargement of the small aortic root during aortic valve replacement: is there a benefit?.Ann Thorac Surg. 2008; 85: 94-100Abstract Full Text Full Text PDF PubMed Scopus (95) Google Scholar] and can be particularly challenging in patients with a calcified aortic root. Previous studies have demonstrated excellent hemodynamic performance for rapid deployment and sutureless valves [3Folliguet T.A. Laborde F. Zannis K. et al.Sutureless Perceval aortic valve replacement: results of two European centers.Ann Thorac Surg. 2012; 93: 1483-1488Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar, 4Borger M.A. Moustafine V. Conradi L. et al.A randomized multicenter trial of minimally invasive rapid deployment versus conventional full sternotomy aortic valve replacement.Ann Thorac Surg. 2015; 99: 17-25Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar]. Furthermore, a recent randomized clinical trial demonstrated significant reductions in early transvalvular gradients and prevalence of patient-prosthesis mismatch—despite a relatively small sample size—in patients receiving a rapid deployment valve compared with similarly sized conventional bioprostheses [4Borger M.A. Moustafine V. Conradi L. et al.A randomized multicenter trial of minimally invasive rapid deployment versus conventional full sternotomy aortic valve replacement.Ann Thorac Surg. 2015; 99: 17-25Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar]. The hemodynamic benefits of these devices, combined with their rapid implantation times and subsequent reduction in myocardial ischemia [3Folliguet T.A. Laborde F. Zannis K. et al.Sutureless Perceval aortic valve replacement: results of two European centers.Ann Thorac Surg. 2012; 93: 1483-1488Abstract Full Text Full Text PDF PubMed Scopus (173) Google Scholar, 4Borger M.A. Moustafine V. Conradi L. et al.A randomized multicenter trial of minimally invasive rapid deployment versus conventional full sternotomy aortic valve replacement.Ann Thorac Surg. 2015; 99: 17-25Abstract Full Text Full Text PDF PubMed Scopus (150) Google Scholar, 5Schlomicher M. Haldenwang P.L. Moustafine V. Bechtel M. Strauch J.T. Minimal access rapid deployment aortic valve replacement: initial single-center experience and 12-month outcomes.J Thorac Cardiovasc Surg. 2015; 149: 434-440Abstract Full Text Full Text PDF PubMed Scopus (28) Google Scholar], may make them an ideal option in elderly patients with a small aortic annulus. In addition, rapid deployment valves appear to facilitate minimally invasive operations. Minimally invasive rapid deployment valve implantation may represent an effective and financially attractive alternative to transcatheter aortic valve replacement procedures in medium-risk elderly patients. One may expect lower paravalvular leak rates and possibly decreased pacemaker implantation requirements compared with transcatheter aortic valve replacement. Results of two large, nearly completed U.S. Food and Drug Administration approval trials will hopefully shed more light on the use of these devices in elderly patients with small aortic annuli and whether they represent a good alternative to transcatheter aortic valve replacement in this patient population. Rapid Deployment of Aortic Bioprosthesis in Elderly Patients With Small Aortic AnnulusThe Annals of Thoracic SurgeryVol. 101Issue 4PreviewAortic valve replacement in elderly patients with a small aortic annulus remains challenging. Patient–prosthesis mismatch (PPM) should be prevented without impacting operative mortality. Hemodynamic benefits resulting from rapid-deployment aortic valve replacement with the Edwards Intuity bioprosthesis for this indication were evaluated. Full-Text PDF