COMMENT
Sutureless valves offer advantages in operative approach and time,
however rates of PVL range from 0.5 to 15.8% and no clear consensus
currently exists regarding management of this
complication.2, 3 We report a case of an Intuity
sutureless AVR complicated by post-operative moderate-to-severe PVL
causing persistent hemolysis. Subsequent BVPD was attempted in
anticipation of expanding the valve’s skirt component but was
unsuccessful in eliminating PVL.
Transcatheter AVR (TAVR) has the highest rate of PVL among AVR
modalities3 leading to clear recommendations in
management. Two strategies, BVPD and deployment of a second
transcatheter valve, “valve-in-valve”, have independently been shown
to reduce PVL and improve overall survival.4 BVPD is
warranted when PVL is moderate-or-greater and may reduce residual
regurgitation by 75.6% in select patients.5
Less literature exists regarding management of PVL following sutureless
AVR. Surgical techniques are described for removal and reimplantation of
a supra-annular malpositioned Perceval sutureless valve (LivaNova,
London, United Kingdom).6 Two cases successfully used
BVPD intra-operatively for PVL, but differ from this case in their
direct access through the aortotomy.7, 8Another study
showed elimination of PVL on POD8 using BVPD in a Perceval sutureless
valve.9 The only report of post-operative BVPD in an
Intuity valve was 6 months after initial
implantation.10 Alternatively, valve-in-valve for PVL
in sutureless valves poses theoretical risks of valve instability and
dislocation, and is not routinely performed.11
In conclusion, despite widespread use of sutureless valves, appropriate
therapeutic modalities for PVL are largely undescribed. To our
knowledge, we are the first to report an attempted BVPD in an Intuity
valve for post-operative PVL, and the only group to describe a failure
of BVPD in the sutureless population. Although potentially beneficial, a
word of caution is important as both the success rate and the
complications remain largely unknown. Further case reports documenting
successful and unsuccessful treatment attempts are necessary to inform
surgical decision making.