Pericardial stentless bioprosthesis

Preliminary results of a modified procedure for implantation

Y. De Bruyne, B. El Nakadi & M. JorisHopitaux civils du CPAS de Charleroi, Belgium.

Pericardial stentless bioprosthesis

Pericardial stentless bioprosthesis

• 37 patients• Male / female: 26/11 • Age: 68 ± 6 ( 53 - 83 ) • Aortic valve lesions:

Stenosis: 16 (43%)

Regurgitation: 10 (27%)

Mixed: 11 (13%)• Endocarditis: 5 (13%)

Pericardial stentless bioprosthesis

– Size of implanted valves:• 21 mm 1• 23 mm 7• 25 mm 12• 27 mm 17

– Associated procedures:• CABG 13• Mitral repair 1

Operative data

Pericardial stentless bioprosthesis

• Group A: Classical– Classical subcoronary implantation (8/37)

• Group B: Banding– Addition of peri-aortic banding (19/37)

• Group C: Vascular prosthesis– Association with replacement of a dilated ascending aorta

(10/37)

Operative groups

Pericardial stentless bioprosthesis

• 8 patients• Regurgitation:

1 mild

1 severe ( reoperated )

Reconsideration of the operative technique

Group A: Classical

Pericardial stentless bioprosthesisImplantation stentless valve dysfunction

Centro-valvular regurgitation

Control of sinotubular

junction diameter

Vascular prosthesisBanding

Pericardial stentless bioprosthesisImplantation stentless valve dysfunction

Centro-valvular regurgitation

Control of sinotubular

junction diameter

Control of commissural

alignment

Vascular prosthesisBanding

Pericardial stentless bioprosthesis

Vascular prosthesis

Banding

Group B Group C

Dilated aorta

Non dilated aorta

Pericardial stentless bioprosthesisImplantation stentless valve dysfunction

Transvalvular gradient

Suppression ofperivalvular

space

Reduction of valvular

obstruction

Adequate scallopping GRF glue

Pericardial stentless bioprosthesisEffect of scallopping on geometry

Cylindrical Possibility of noncylindrical implantation

Pericardial stentless bioprosthesisImplantation stentless valve dysfunction

Centro-valvular regurgitation Transvalvular gradient

Control of sinotubular

junction diameter

Control of commissural

alignment

Vascular prosthesis

Suppression ofperivalvular

space

Banding

Reduction of valvular

obstruction

Adequate scallopping GRF glue

Pericardial stentless bioprosthesis

• S-shaped aortotomy

• Aortic wall extensively freed of calcifications

• Size of the prosthesis defined by the diameter of

the aortic annulus

• Trimming of the inferior rim of the prosthesis

• Inflow suture line: 3 running sutures (Baratt-Boyes)

• Scallopping of the three sinuses

• Outflow suture line: 3 running sutures

Group B: Banding (19 patients )

Pericardial stentless bioprosthesis

• Dacron strip length :

C = 3,5 * [prosthesis diameter]

(perimeter + aortic wall thickness)

• GRF Glue

• Extra-aortic knots of the distal suture line anchoring

the Dacron banding

• Closure of the aortotomy

• Fastening of the banding

Group B: Banding (19 patients )

Pericardial stentless bioprosthesis

• Dilated ascending aorta (more than 40 mm)

• Transsection at the sinotubular junction

• Valve replacement (± plicatures of the aortic wall)

• Vascular prosthesis (1 mm larger than the valve)

• Proximal running suture supporting the valvular

commissures

• Distal running suture line

Group C: Vascular prosthesis (10 patients )

Pericardial stentless bioprosthesis

Cross-clamping time

Simple valve replacement

Replacement associated with

other procedures

Group A 95 ± 20 107 ± 14

Group B 93 ± 18 119 ± 17

Group C 98 ± 15 140

Pericardial stentless bioprosthesis

group A group B group C

Number of patients 8 19 10

Early mortality 1 pulmonary 1 sepsis 1 pulmonary

13% 5% 10%

Late mortality 1 cardiogenic 1 pulmonary 0

13% 5% 0%

Valve related mortality 0 0 0

Survival 75% 89% 90%

mean follow-up 22 months 12 months 12 months

Survival

Pericardial stentless bioprosthesis

group A group B group C

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Post-op 7/8 100% 0% 0% 17/19 100% 0% 9/10 100%

3-6 months 4/6 50% 25% 25% 14/18 100% 0% 6/9 100%

> 1 year 3/5 100% 0% 0% 6/17 83% 17% 3/9 100%

Echocardiographic valve regurgitation

Pericardial stentless bioprosthesis

• The pericardial stentless bioprosthesis can be used in any pathologic condition requiering aortic valve replacement.

• An appropriate peri-aortic banding seems to secure an adequate geometrical valve implantation.

• Combined replacement of the aortic valve and a part of the ascending aorta seems to be a good alternative for a root replacement.

Conclusion

Pericardial stentless bioprosthesis

group A group B group C

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Post-op 7/8 86% 14% 0% 0% 17/19 82% 18% 0% 9/10 100% 0%

3-6 months 4/6 25% 25% 25% 25% 14/18 79% 21% 0% 6/9 83% 17%

> 1 year 3/5 67% 33% 0% 0% 6/17 83% 0% 17% 3/9 67% 33%

Echocardiographic valve regurgitation

Pericardial stentless bioprosthesisControl of

sinotubular junction diameter

Cylindrical configuration of the prosthesis

Pericardial stentless bioprosthesisControl of

commissuralalignment

Cylindrical configuration of the prosthesis

Pericardial stentless bioprosthesis

Suppression ofperivalvular

space

Reduction of valvular

obstruction

Adequate scallopping

GRF glue

Pericardial stentless bioprosthesis

Nbr Meanf .u.

(months)

T.O.E. T.T.E.(3-6 m.)

T.T.E.(>1y.)

Peri-aorticbandig

19 11.8 17 14 6

Combinedreplacement

10 12 9 6 3

Follow-up