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