Christian Hagl

Although minimally invasive aortic valve replacement (AVR) has been proposed to cause less morbidity in patients, it still has not seen broad application. The study aim was to evaluate the implantation of the self-anchoring aortic valve (Perceval S; Sorin) via a mini-sternotomy. As a part of a multicenter, European, prospective, non-randomized, clinical trial, 35 patients (30 females, five males; mean age 80 +/- 4 years) with isolated aortic valve stenosis (mean gradient 48 +/- 21 mm Hg) were operated on at the authors' center. Perceval S self-anchoring valves were implanted following a mini-sternotomy, extracorporeal circulation (ECC), aortic cross-clamping, cardioplegic arrest and removal of the calcified native valve. The mean EuroSCORE and STS score were 12 +/- 9% and 4 +/- 2%, respectively. There were no failures of deployment, and nor was there any intra-procedure or 30-day mortality. The mean ECC-time was 70 +/- 24 min, and cross-clamp time 34 +/- 10 min. The valve implantation time was 9 +/- 5 min. Perioperative echocardiography revealed no significant aortic insufficiency or paravalvular leakage. The postoperative mean gradient was 16 +/- 6 mmHg. At follow up, there was no paravalvular leakage or significant valvular insufficiency. No migration or dislodgement of the prosthesis occurred. This trial highlights the advantages of the Perceval S self-anchoring valve which, technically is a more reproducible alternative for minimally invasive AVR. As the valve does not need to be sutured, the limited exposure is not a disadvantage even in patients with calcified or small aortic roots. This also potentially reduces the cross-clamp and ECC-times. This valve may enable a broader application of minimally invasive AVR.

The Bentall procedure is the 'gold standard' for the repair of a combined pathology of ascending aorta and aortic valve. Because there is no need for long-term anticoagulation, biological-valved conduits have become increasingly popular; however, the possible need for reoperation due to valve degeneration is a major disadvantage. The aim of this animal-based study was to prove the feasibility of an isolated replacement of the aortic valve prosthesis six months after a previous implantation of a biological valved conduit (BioValsalva) in a sheep model. A total aortic root replacement, using the BioValsalva conduit, was performed in 10 juvenile sheep. After six months, the surviving sheep were reoperated on, and the stentless valve was replaced with a stented biological valve placed inside the previously implanted vascular conduit. Five animals survived the initial implantation of a BioValsalva conduit. During reoperation, the triple-layered vascular graft with polytetrafluoroethylene on the outside showed only slight adhesions with the surrounding tissue. The stentless valve was removed in one piece, after which a new stented valve was implanted inside the conduit. An X-radiographic examination of the explanted valve showed moderate calcification of the leaflet, and severe calcification of the aortic wall. The results of this animal study confirmed that a degenerated stentless biological valve inside the BioValsalva conduit could be replaced with a new valve, without having to remove the entire conduit.

We present a case of sternal steel strut dislodgement and migration in a patient undergoing Ravitch repair for pectus excavatum (PE) 37 years ago. Broken struts perforated the right ventricle and right ventricular outflow tract (RVOT) and additionally migrated into the left upper lobar bronchus.

Aortic dissection is one of the the most common and lethal catastrophes involving the aorta. Speedy diagnosis, as well as appropriate therapy are essential for survival of the patients. Because the clinical presentation in patients suffering AADA can differ substantially, discussion concerning specific surgical therapy remains controversial. This implies questions regarding the treatment of the aortic root as well as the aortic arch and the proximal descending aorta. The current manuscript raises important issues regarding surgical treatment of AADA patients which are discussed in the light of the institutional policy in the author’s department.

Composite replacement is the standard treatment for the repair of aortic aneurysm with aortic valve pathology. With improved long-term durability and no requirement for long-term anticoagulation, tissue-valved conduits have become increasingly popular. Herein are reported the results achieved with 50 consecutive 'Bentall' operations, using the first commercially available prefabricated stentless tissue-valved conduit (Vascutek BioValsalva). Between September 2007 and September 2009, a total of 50 patients (10 females, 40 males; mean age 65 +/- 7 years) received a BioValsalva conduit. Concomitant procedures included coronary artery bypass grafting (CABG; n = 15), other valve (n = 5), and aortic arch replacement with circulatory arrest (n = 20; three of these had an additional frozen elephant trunk). Four of the procedures were re-operations. A six-month follow up with echocardiography and clinical examination was completed in 25 patients. The 30-day mortality was 8% (4/50). Three of these patients underwent concomitant procedures. The cardiopulmonary bypass (CPB) and cross-clamp times were 178 +/- 30 min and 106 +/- 7 min, respectively. The triple-layered vascular graft proved to be hemostatic, without suture-line bleeding. Both, the initial and follow up echocardiography showed no valvular insufficiency, with a mean gradient of 13 +/- 5 mmHg. All patients were in NYHA class I-II. The BioValsalva prefabricated tissue-valved conduit showed very good early results. The ischemic time required to construct a 'home-made' stentless tissue-valved conduit was eliminated, thus reducing the cross-clamp time. The conduit also offered the hemodynamic advantages of a stentless valve.

A European, multicenter, prospective, non-randomized, clinical pilot trial was designed to evaluate the feasibility of the Perceval S sutureless aortic valve prosthesis. A clinical and echocardiographic follow up was performed at the time of hospital discharge and subsequently after one, three, six, and 12 months. The valve was implanted following sternotomy, extracorporeal circulation (ECC), aortic cross-clamping, cardioplegic arrest, and removal of the native valve. Implantation suturing was not required. Optimal annular sealing was obtained with brief low-pressure balloon dilation. If coronary bypass was indicated, a distal anastomosis was performed first. Between April 2007 and February 2008, 30 patients (mean age: 81 +/- 4 years) underwent aortic valve replacement. The prevalence of pure aortic stenosis was 76.7%, and that of mixed lesion 23.3%. The mean logistic EuroSCORE was 13.18%, and the NYHA class was III and IV in 93.3% and 6.7% of patients, respectively. The implanted valve size was 21 and 23 mm in 37% and 63% of patients, respectively, and 14 (46.7%) underwent coronary artery bypass grafting (11 internal mammary artery, nine vein grafts). The mean aortic cross-clamp and ECC times were 34 +/- 15 min and 59 +/- 21 min, respectively. There was one in-hospital death (3.3%), and three deaths occurred within 12 months of follow up (one death was valve-related, and two deaths were independent of the valve implantation). A total of 28 patients was assessed at one month post-implantation, and 23 after 12 months. No migration or dislodgement of the valve had occurred, but there were two mild paravalvular leakages and two mild intravalvular insufficiencies. The preliminary results of the trial confirmed the safety and efficacy of the Perceval S sutureless aortic valve. In this high-risk subset of patients, shortening the aortic cross-clamp and ECC times may help to reduce mortality and morbidity.

We thank Mr Abunasra and co-workers for their comments and interest in our work [1].