1. Pericardial stentless bioprosthesis Preliminary results of a modified procedure for implantation Y. De Bruyne, B. El Nakadi & M. Joris Hopitaux civils du CPAS de Charleroi, Belgium.

2. Pericardial stentless bioprosthesis

3. 37 patients Male / female: 26/11 Age: 68 ± 6 ( 53 - 83 ) Aortic valve lesions: Stenosis:16 (43%) Regurgitation:10(27%) Mixed:11(13%) Endocarditis: 5 (13%)

4. Pericardial stentless bioprosthesis – Size of implanted valves: 21 mm 1 23 mm 7 25 mm 12 27 mm 17 – Associated procedures: CABG 13 Mitral repair 1 Operative data

5. Pericardial stentless bioprosthesis Group A: Classical –Classical subcoronary implantation (8/37) Group B: Banding –Addition of peri-aortic banding (19/37) Group C: Vascular prosthesis –Association with replacement of a dilated ascending aorta (10/37) Operative groups

6. Pericardial stentless bioprosthesis 8 patients Regurgitation: 1 mild 1 severe ( reoperated ) Reconsideration of the operative technique Group A: Classical

7. Pericardial stentless bioprosthesis Implantation stentless valve dysfunction Centro-valvular regurgitation Control of sinotubular junction diameter Vascular prosthesisBanding

8. Pericardial stentless bioprosthesis Implantation stentless valve dysfunction Centro-valvular regurgitation Control of sinotubular junction diameter Control of commissural alignment Vascular prosthesisBanding

9. Pericardial stentless bioprosthesis Vascular prosthesis Banding Group BGroup C Dilated aorta Non dilated aorta

10. Pericardial stentless bioprosthesis Implantation stentless valve dysfunction Transvalvular gradient Suppression of perivalvular space Reduction of valvular obstruction Adequate scallopping GRF glue

11. Pericardial stentless bioprosthesis Effect of scallopping on geometry Cylindrical Possibility of non cylindrical implantation

12. Pericardial stentless bioprosthesis Implantation stentless valve dysfunction Centro-valvular regurgitationTransvalvular gradient Control of sinotubular junction diameter Control of commissural alignment Vascular prosthesis Suppression of perivalvular space Banding Reduction of valvular obstruction Adequate scallopping GRF glue

13. Pericardial stentless bioprosthesis S-shaped aortotomy Aortic wall extensively freed of calcifications Size of the prosthesis defined by the diameter of the aortic annulus Trimming of the inferior rim of the prosthesis Inflow suture line: 3 running sutures (Baratt-Boyes) Scallopping of the three sinuses Outflow suture line: 3 running sutures Group B: Banding (19 patients )

14. Pericardial stentless bioprosthesis Dacron strip length : C = 3,5 * [prosthesis diameter] (perimeter + aortic wall thickness) GRF Glue Extra-aortic knots of the distal suture line anchoring the Dacron banding Closure of the aortotomy Fastening of the banding Group B: Banding (19 patients )

15. Pericardial stentless bioprosthesis Dilated ascending aorta (more than 40 mm) Transsection at the sinotubular junction Valve replacement ( ± plicatures of the aortic wall) Vascular prosthesis (1 mm larger than the valve) Proximal running suture supporting the valvular commissures Distal running suture line Group C: Vascular prosthesis (10 patients )

16. Pericardial stentless bioprosthesis Cross-clamping time

17. Pericardial stentless bioprosthesis Survival

18. Pericardial stentless bioprosthesis Echocardiographic valve regurgitation

19. Pericardial stentless bioprosthesis The pericardial stentless bioprosthesis can be used in any pathologic condition requiering aortic valve replacement. An appropriate peri-aortic banding seems to secure an adequate geometrical valve implantation. Combined replacement of the aortic valve and a part of the ascending aorta seems to be a good alternative for a root replacement. Conclusion

20. Pericardial stentless bioprosthesis Echocardiographic valve regurgitation

21. Pericardial stentless bioprosthesis Control of sinotubular junction diameter Cylindrical configuration of the prosthesis

22. Pericardial stentless bioprosthesis Control of commissural alignment Cylindrical configuration of the prosthesis

23. Pericardial stentless bioprosthesis Suppression of perivalvular space Reduction of valvular obstruction Adequate scallopping GRF glue

24. Pericardial stentless bioprosthesis Follow-up