Bicuspid Aetiology And Rapid Deployment Aortic Valve Implantation In Minimally Invasive Aortic Valve Replacement: Ballet En Pointe.
Romy R.M.J.J. Hegeman, Idserd Klop, Martin J. Swaans, Patrick Klein.
St. Antonius Hospital, Nieuwegein, Netherlands.
BACKGROUND: Bicuspid aortic valve (BAV) morphology is the most prevalent congenital cardiac disorder and is the predominant cause of severe aortic valve stenosis in patients ≤ 70 years. Minimally-invasive aortic valve replacement (MIAVR) has small but significant advantages over conventional aortic valve replacement (AVR) by full median sternotomy and is greatly facilitated by the use of a rapid deployment stented bioprosthesis (RDSBP). However, BAV forms a relative contraindication for the use of these protheses due to the anatomical derangements of the aortic root and the risk of paravalvular leakage (PVL). Modifications of the implant technique of a RDSBP in BAV morphology enable implantation without increased risk for PVL and can facilitate MIAVR.
METHODS: A retrospective analysis of our single center experience with the Intuity Elite RDSBP in MIAVR was performed. Procedural data and early outcome were reported for all patients. Technical modifications of the implant procedure were used to enable safe implantation of the Intuity Elite valve in BAV morphology, such as the use of more than three guiding sutures or non-classical placement of the guiding sutures.
RESULTS: Between May 2015 and December 2021, 32 patients with BAV morphology (Sievers type 0, 1a, 1b and 2 in respectively 1, 24, 5 and 2 patients) underwent MIAVR with implantation of the Intuity Elite RDSBP by a single surgeon. Additional guiding-sutures were placed depending on valve morphology. Mean age of operated patients was 69±7 years, 69% of patients were male. MIAVR was conducted via upper hemi-sternotomy (n=29) or right anterior thoracotomy (n=3). There were no conversions to full median sternotomy. Mean cardiopulmonary bypass time was 70±18 min. Mean aortic cross clamping time was 47±11 min. Perioperative mild PVL occurred in one patient and increased over time, after which successful percutaneous closure was performed. There was no in-hospital mortality. One patient had a stroke with full functional recovery. Two patients required permanent pacemaker implantation.
CONCLUSIONS: Small modifications of the implant technique of the Intuity Elite RDSBP facilitates safe implantation in bicuspid morphology, enabling a minimally invasive approach also in these potentially challenging patients. 
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