Technical Details of Aortic Valve Replacement using Carpentier–Edwards PERIMOUNT Magna Ease Aortic Bioprosthesis in a Sexagenarian Patient with Severe Calcific Aortic Stenosis: A Video Presentation

Introduction The current guidelines of the American Heart Association (AHA), American College of Cardiology (ACC) from 2014, and the European Society of Cardiology (ESC) from 2012 uniformly recommend mechanical aortic valve replacement in patients under 60 years of age and biologic aortic valve replacement in patients over 70 years of age.[ 1 ] [ 2 ] The recommendations are conflicting for patients between 60 and 70 years of age. The ESC guidelines recommend biologic prosthesis from the age of 65 years onward, whereas the newer AHA/ACC guidelines only recommend biological valves starting 70 years of age. Over the past 20 years, there is a shift away from a clear-cut age limit toward patient’s wish and lifestyle considerations.[ 3 ] The number of surgical aortic valve replacements using a bioprosthesis is increasing according to the annual surveys of thoracic surgery in 2013 and 2014 by the Japanese Association for Thoracic Surgery, which states that bioprostheses are used in three-quarters of all aortic valve replacements procedures.[ 4 ] In addition, the age limit for implantation of an aortic bioprosthesis is continuously being shifted down with bioprostheses used for aortic valve replacements in 60% of sexagenarian patients and 90% of septuagenarian or octogenarian patients.[ 3 ] [ 4 ] [ 5 ] [ 6 ] This may be related to the enhanced durability of new-generation bioprostheses, improved outcomes of redo valve replacement surgery, or the development of valve-in-valve (ViV) transcatheter aortic valve implantation.[ 3 ] [ 4 ] [ 5 ] [ 6 ] Randomized trials comparing biological and mechanical valve replacements are scanty. In 2009, Stassano and associates randomized 310 patients between 55 and 70 years of age into a mechanical and a biological prosthesis group to undergo aortic valve replacement. At a mean follow-up of 4 years, they found similar mortality and other adverse prosthesis-related events, namely, thromboembolic complications, bleeding, endocarditis, and structural valvular deterioration in the two group of patients.[ 7 ] In 2008, Brown and associates analyzed outcome after aortic valve replacement with mechanical versus biological prosthesis in patients aged between 50 and 70 years at operation. Freedom from reoperation was 98% for mechanical valve and 91% for bioprosthesis ( p = 0.06). Rehospitalization for hemorrhagic events occurred in 15% of patients with mechanical valves and 7% of patients with bioprosthesis ( p = 0.001). The 5- and 10-year unadjusted survivals were 87% and 68% for mechanical valves and 72% and 50% for bioprosthesis, respectively.[ 8 ] The reported incidence of survival following mechanical mitral valve replacement in the published literature at 10, 20, and 30 years was 61 to 75%, 36.5 to 39% and 22.6%, respectively.[ 9 ] [ 10 ] [ 11 ] [ 12 ] [ 13 ] [ 14 ] The Carpentier–Edwards pericardial prosthesis commercially available since 1980 is the bioprosthesis, which is the most used worldwide. As a second-generation pericardial bioprosthesis, the Carpentier–Edwards pericardial valve was designed to minimize structural valvular deterioration, which plagued the first-generation prosthesis while retaining the hemodynamic superiority conferred by pericardial valve substitutes.[ 14 ] [ 15 ] [ 16 ] [ 17 ] Published literature documents excellent long-term outcomes with the Carpentier–Edwards pericardial valve ([ Table 1 ]).[ 15 ] [ 18 ] [ 19 ] [ 20 ] [ 21 ] [ 22 ] Table 1 Long-term outcomes assessment for structural valve deterioration with Carpentier–Edwards stented bioprosthesis Model Author Follow-up maximum, mean (years) Time of structural valve deterioration estimate (years) Age (years) Freedom from structural valve deterioration estimate (%) Abbreviations: CI, confidence interval. Carpentier–Edwards Poirier et al[ 15 ] 15, 4.8 14 Mean (not reported) < 60 60–69 ≥70 79.9 ± 5.0 84.7 87.9 100 Carpentier–Edwards Neville et al[ 18 ] 12, 4.7 12 Mean 68 < 60 ≥60 94 (CI: 90–98) 89 (CI: 80–98) 98 (CI: 96–100) Carpentier–Edwards Banbury et al[ 19 ] 17, 12 15 Mean 65 < 50 50–70 ≥70 77 (CI: 74–82) 48 80 90 Carpentier–Edwards Dellgren et al[ 22 ] 14, 5 12 Mean 71 > 65 86 ± 9.0 100 Carpentier–Edwards Biglioli et al[ 20 ] 18, 6.0 18 Mean 67 < 65 ≥65 52.9 ± 9.9 35.8 ± 10.7 83.7 ± 8.9 Carpentier–Edwards McClure et al[ 21 ] 17, 6.0 15 Mean 74 < 65 65–75 ≥75 82.3 (CI: 67–91) 34.7 CI: 6–67) 99.5 (CI: 97–99.9) 99.5 (CI: 97–99.0) The PERIMOUNT Magna Ease which is a further development of the PERIMOUNT Magna prosthesis (Edwards Lifesciences, Irvine, CA, USA) belongs to the latest generation of aortic valve prostheses. The manufacturers points the following advantages: lower profile, contoured and complaint sewing rings, and larger effective orifice areas, which would result in easier insertion and higher coronary ostial clearance; further, it lowers transprosthetic gradients and avoids prosthesis-patient mismatch; also, lower gradients together with an anticalcification technology prevents early structural valve deterioration.[ 23 ] [ 24 ] [ 25 ] Although the Carpentier–Edwards PERIMOUNT Magna Ease valve is a bioprosthesis with documented excellent hemodynamics and other advantages as stated above, the valve has a gap between the cobalt-chromium-nickel alloy stent and silicone sewing ring. This gap, which is widest just below each of the three commissural struts, lacks silicone and leaves the two-layer polytetrafluoroethylene fabric unprotected. The passage of a needle through this weak area may result in fabric tear, resulting in a true cuff leakage and not the usual paravalvular leakage. To date, there are four case reports of cuff leakage in the literature diagnosed by transesophageal echocardiography. Three patients with cuff leakage were managed conservatively, and in one patient, it was sutured using polypropylene suture.[ 26 ] [ 27 ] [ 28 ] [ 29 ] Pledgeted mattress sutures like we have used in our case in this manuscript have been advocated by other authors to prevent this complication.[ 29 ] We report herein a 61-year-old male patient (body surface area 1.7 m 2 ) diagnosed with severe calcific aortic stenosis, with a peak systolic left ventricle-to-aortic gradient of 110 mm Hg and normal coronaries undergoing aortic valve replacement using a 21 mm Carpentier–Edwards PERIMOUNT Magna Ease aortic prosthesis under moderately hypothermic cardiopulmonary bypass, St. Thomas (II)-based cold blood cardioplegia and iced normal saline. Postoperative recovery was uneventful. Publication History Article published online: 03 November 2020 © 2020. 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