SUTURELESS AORTIC VALVE REPLACEMENT USING THE PERCEVAL S PROSTHESIS: SHOULD BICUSPID DISEASE BE A CONTRAINDICATION?

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Sutureless aortic valve replacement (AVR) is a relatively new technique for the treatment of aortic stenosis. Bicuspid aortic valve is generally considered a contraindication to sutureless AVR. The aim of this study was to evaluate the feasibility and perioperative outcomes of this technique in patients with bicuspid aortic disease. Between June 2011 and January 2014, 25 patients with aortic bicuspid disease underwent sutureless AVR. Data were collected from preoperative and postoperative transthoracic echocardiography reports (maximum 28 days post-op) and from intensive care unit charts. Surgical approach consisted in a median sternotomy in 13 patients (52%), partial sternotomy in 5 (20%) and minithoracotomy in 7 (28%). Due to advanced age and presence of comorbidities, these patients were selected for AVR. Sutureless AVR was successfully performed in all patients (n=25, 100%). The study population included 17 (68%) male and 8 (32%) female, with a median age of 77.8 ± 5.4 years old. Eleven (44%) of these patients had a preoperative New York Heart Association functional class of III-IV/IV. The mean Euroscore II was 3.4 ± 2.6 %. Concomitant procedures included CABG in 8 patients (32%), ascending aortic replacement in 2 (8%), mitral valve repair in 1 (4%), septal myomectomy in 1 (4%) and atrial septal defect closure in 1 (4%). Mean aortic cross-clamp time was 46 ± 14 minutes in patients who had sutureless AVR alone and 56 ± 14 minutes in those who had concomitant procedures. Mean trans-aortic valve gradient decreased from an average of 49.4 ± 15.7 mmHg preoperatively to 14.5 ± 5.4 mmHg postoperatively. Mean aortic valve area increased from 0.78 ± 0.18 cm2 preoperatively to 1.75 ± 0.43 cm2 postoperatively. Five patients suffered from atrio-ventricular block requiring permanent pacemaker implantation. Two patients suffered from stroke, one of which resulted in permanent hemiparesis. There was no paravalvular leak at the pre-discharge TTE. No postoperative valve migration or embolization was reported. In-hospital mortality occurred in one patient (4%). Mean ICU length of stay was 3 ± 2 days postoperatively. This study demonstrates that Perceval S sutureless valve can be deployed in patients with bicuspid aortic disease without increasing the risk of paravalvular leak, allowing short cross-clamp times, satisfactory postoperative mean trans-aortic gradients and good perioperative mortality and morbidity, considering the high baseline risk status of this population. Bicuspid aortic valve disease should not be considered a contraindication to sutureless AVR.