Introduction
Bicuspid aortic valve (BAV) is a common congenital heart condition
affecting approximately 0.5% of the population.1 In
its pure form, a Type 0 BAV results from two aortic cusps without any
raphes whereas BAV Type 2 occurs with two raphes. Type 1 BAV is the most
common form with one raphe and is particularly associated with fusion of
the right and left cusps.2 The need for surgery of the
aortic valve and/or aorta is increased in patients with BAV, with one
study showing a 27% incidence of a surgical event over a 20-year
period.3 Additionally, up to one third of patients
undergoing aortic valve replacement may also require aortic root
surgery.4
The advent of sutureless and rapid-deployment valves has facilitated
surgery for patients who would otherwise not be a surgical candidate due
to frailty or prolonged surgical procedures. Sutureless valves
(Perceval Sorin (LivaNova group) Sutureless Aortic Heart
Valve (Perceval) and 3f Enable (ATS Medical) Aortic
Bioprosthesis (3f Enable)) consist of three biological pericardial
leaflets mounted within a self-expanding Nitinol
frame.5 Upon expansion, these prostheses are
stabilized in place by radial outward force without relying on permanent
suturing to the patient’s aortic annulus.6 The
Perceval valve is inserted using a transverse aortotomy with temporary
guiding sutures at the nadir of each sinus in the annulus and passed
through the eyelets of each valve.7 Commissural
traction sutures are removed following visual confirmation of correct
valve placement, and the balloon is then inflated at 4 atm for 30
seconds.8 Following deflation, the catheter is
removed. The 3f Enable valve is also inserted using a transverse
aortotomy, although its implantation is slightly different. When
inserting the 3f Enable valve, its commissural tabs are attached to the
aorta (near the level of the native aortic annulus) and spaced at
120-degree intervals. The commissural tabs are fixated using three
mattress sutures with pledgets, two lateral sutures, and one horizontal
suture once the inner holder has been removed.9 It
should be noted that this device was discontinued in May 2015 for safety
concerns. The rapid-deployment valve (Intuity (Edwards
Lifesciences) valve (Intuity)) consists of three biological
pericardial leaflets anchored to a balloon-expandable, stainless steel
cloth-covered frame that is incorporated into the valve
inflow.10 For Intuity rapid deployment valve
insertion, a hockey stick aortotomy should be performed and extend
obliquely across the sinotubular junction to the middle of the
noncoronary sinus. Similar to the Perceval sutureless valve insertion,
the native leaflets should be excised and debridement of the annulus
should be conducted. Three equidistant guiding sutures should be placed
at the nadir of each coronary cusp, and exit 2-3 mm above the annulus.
Using the guiding sutures, the valve should be parachuted using the
associated delivery system perpendicularly into the annulus. Once the
valve has been determined to be correctly positioned, the balloon is
inflated to 4.5-5 atm and maintained for 10 seconds prior to deflating
it. Following deflation, the delivery system is removed and the three
guiding sutures are cut and serially tied.
BAV has traditionally been considered a relative contraindication for
the use of sutureless and rapid-deployment prostheses due to anatomic
concerns surrounding valve implantation. These concerns were primarily
due to how uneven alignment of the two cusps and aortic root asymmetry
in BAV may result in paraprosthetic leak.11 In recent
years, numerous studies have attempted to expand sutureless and
rapid-deployment valves to the BAV patient population. The purpose of
this scoping review is to describe the outcomes and complication rates
of patients BAV undergoing aortic valve replacement with the Perceval
sutureless prosthesis, 3f Enable sutureless prosthesis, or Edwards
Intuity rapid-deployment prosthesis.