Aortic Valve Replacement Using a Perceval Sutureless Aortic Bioprosthesis  David Heimansohn, MD, Sina Moainie, MD  Operative Techniques in Thoracic and Cardiovascular Surgery  Volume 21, Issue 4, Pages 282-305 (December 2016) DOI: 10.1053/j.optechstcvs.2017.09.004 Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 1 Ministernotomy incision for AVR. (A) The sternal incision is performed as a “J” incision, from the sternal notch caudally and curved into the right third or fourth intercostal space. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 1 Continued (B) This allows access to the ascending aorta and the aortic valve. SVC = superior vena cava. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 2 Cannulation can be performed directly or using a femoral approach (A). Aortic cannulation through the sternal incision can be easily done using a guidewire-directed cannula and transesophageal echocardiography guidance (B). Venous cannulation can be done using the femoral approach, which allows a smaller chest incision (C). This can be done under ultrasound guidance to facilitate percutaneous placement. CBP = cardiopulmonary bypass. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 3 Aortic cross-clamping is performed using a minimally invasive clamp through the incision, or using a small lateral incision. Cardioplegia is simplified with a single-dose regimen through an antegrade approach, such as Del Nido or Custodiol cardioplegia. A right pulmonary vein left ventricular vent can be placed in most instances. CBP = cardiopulmonary bypass. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 4 (A) The aortotomy is a transverse incision placed near the aortic fat pad, usually 3-4 cm above the right coronary ostium. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 4 Continued (B) The aorta is divided about 50% of its circumference, which allows good exposure of the aortic valve. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 4 Continued (C) Suture retraction is used in 3 or 4 locations to lift the aortic root toward the incision and to maximize aortic valve visualization. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 5 (A) The valve is removed in its entirety and complete annular debridement of all calcification is performed. Complete debridement allows easier valve implantation and better coaptation of the valve to the annulus with less risk of paravalvular leak. If any defects are created during debridement, they are repaired before valve placement. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 5 Continued (B) Sizing is done using Perceval sizers starting with the smallest sizer. Sequential sizing is performed until the sizer is reached, which passes though the annulus on the translucent disk but not the opaque disk. This will correspond to the valve size that best fits the annulus. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 6 (A) The valve is a nitinol frame supporting a valve composed of bovine pericardial tissue. Suture guide eyelets are present on the inflow ring to allow precise placement during the implant. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 6 Continued (B) The chosen valve is prepared by placing it on the deployment device using a collapsing system designed for the chosen valve size. The valve is reduced in size but not crimped to avoid leaflet tissue damage. The suture guide eyelets are exposed to guide the depth of implantation. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 6 Continued (C) The reduced size of the valve and the long deployment catheter allow the valve to be implanted through a small incision, requiring no manipulation of the annulus. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 7 (A) The surgeon places guiding sutures below the annulus while other members of the surgical team prepare the valve for implantation. Sutures of 3-0 prolene are used and are placed 2-3 mm below the annulus at the nadir of each sinus. These will correspond to the suture eyelets on the valve that are evenly spaced circumferentially at 120°. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 7 Continued (B) The guiding suture at the right coronary artery sinus should be placed slightly higher at 1-2 mm below the annulus to help prevent conduction system damage and postoperative heart block. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 8 The valve is lowered into place (A) and moderate tension is applied to the guiding sutures by the surgeon and assistant while the valve is released (B). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 8 The valve is lowered into place (A) and moderate tension is applied to the guiding sutures by the surgeon and assistant while the valve is released (B). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 8 Continued The inflow ring is released first by turning the unlocking knob clockwise (C). Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 8 Continued The outflow ring is then removed by removing the clip and withdrawing the sleeve (D). The deployment catheter is then carefully removed, taking care not to move the valve. The valve is inspected in the following manner: verify that the longitudinal struts of the frame are parallel, the leaflet is symmetrical, and finally, minimal annulus shows above or below the valve. If concerns occur in any part of the inspection, the valve should be removed and redeployed. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 9 Balloon dilatation is performed with the corresponding balloon that is placed inside the deployed valve to a depth that places the ring on the balloon catheter at the top of the valve leaflets. It is then inflated with saline at 4 atmospheres while gently irrigating with warm saline for 30 seconds. The balloon is deflated and removed. Again complete inspection is performed. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 10 (A) The aorta is then closed with 4 or 5-0 prolene suture. The cross clamp is removed, deairing is performed, and the patient is weaned off cardiopulmonary bypass. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions

Figure 10 Continued (B) The valve is checked for leaflet motion, annular position, and the presence of aortic insufficiency. If any abnormalities exist, consideration should be given to valve redeployment. Operative Techniques in Thoracic and Cardiovascular Surgery 2016 21, 282-305DOI: (10.1053/j.optechstcvs.2017.09.004) Copyright © 2017 Elsevier Inc. Terms and Conditions