DISCUSSION
Redo aortic valve surgery in small aortic roots and previously implanted mechanical or tissue bioprosthesis can be a challenge [1].The redo operation has three objectives: perform a safe operation with careful access, minimize cardiopulmonary bypass time and insert a prosthesis with optimal size and gradients in order to prevent PPM [2]. In the present case, the decision of using a Sapien valve was based on the increased surface area with low gradients in a small annulus that was accepted already at the previous operation. Moreover, the use of an annulus enlargement technique was not an option as it could be a challenge with increasing surgical times [3].
The last generation of the Sapien valves proved excellent results, good stability and easy implantability during valve-in-valve procedures. A metanalysis by Tam et al [4] suggested that using the valve-in-valve technique in high-risk cases results are comparable with redo high-risk surgery. Using the expandable valve, studies suggested a less length of hospital stay and less incidence of pacemaker implantation when compared to standard procedures [1].
Using the transcatheter valve during an open operation, when the failed prosthesis is totally removed leaves a rough area for the implantation of the transcatheter valve. In this contest, the coronary obstruction becomes possible, as most of these small roots have been decalcified when the pathological native valve was removed. This can create an abnormal area that can make distortions of the annulus near the coronary ostia. Therefore, careful analysis of the type of the valve that need to be implanted with all the characteristics including the height, the size and the structural characteristics is very important. If a coronary obstruction happens with a Sapien, we confirm that part of the skirt can be safely and easily removed to guarantee the flow. Probably, a “surgical model” of Sapien valve with no skirt at the level of the coronary ostia can avoid this complication.
Authors ‘contributions :
Concept/design: EF, TT
Data analysis/interpretation: EF, TT, SD
Drafting article: TT, EF, SC, DT
Critical revision of article: TT, EF
Approval of article: SD, EF, TT
Data collection: DT