Supra-Annular Perceval Bentall: From Concept to Patient

OBJECTIVE: To demonstrate a supra-annular implantation of a composite valve-graft (CVG) constructed from a sutureless aortic valve within a Dacron graft for aortic root replacement. The anatomic rationale, preclinical validation, and clinical outcomes of this novel technique are described. METHODS: The anatomic rational for sizing of the valve and graft was examined by ex vivo implantation of a Perceval Plus XL valve (Corcym, Milan, Italy) within a 28 mm Valsalva Dacron graft (Terumo Aortic, Inchinnan, UK). Hydrodynamic in vitro testing with a ViVitro pulse duplicator system (ViVitro, Victoria, BC, Canada) validated the integrity of the CVG. The CVG was implanted supra-annular to the native aortic annulus in a clinical setting. RESULTS: A Perceval XL valve within a 28 mm Valsalva Dacron graft provided 8% oversize of the valve inflow ring within the graft collar. In vitro testing showed valve stability within the Dacron graft under physiologic conditions. The first SUpra-annular PERceval Bentall (SUPERB) was performed in a 75-year-old male patient with concomitant aortic stenosis and aortic root aneurysm. The CVG was constructed by (1) suturing the graft to the aortic annulus, (2) construction of coronary buttons, and (3) deployment of the sutureless valve with the Dacron graft in a supra-annular position. CONCLUSIONS: SUPERB uses a Perceval XL valve within a 28 mm Valsalva Dacron graft for aortic root replacement. Positioning of the sutureless valve within the Dacron graft and supra-annular to the native aortic annulus decouples valve sizing from the restrictions of native aortic annular dimensions. This approach simplifies CVG sizing and potentially mitigates patient-prosthetic mismatch.