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The Stentless Valve Concept

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Surgical Management of Aortic Pathology

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Abstract

After almost 40 years of clinical use, stentless valves are unequivocally considered the ideal bioprostheses, similar to native valves, by a group of enthusiastic implanters, as well as useless, complicated, technically demanding devices with unclear indications by the skeptical majority in the surgical community.

Understanding stentless valves requires a deep knowledge of the aortic root anatomy and dynamics which is far more complex than the simple open/close leaflets mechanism. In fact, each of the following structures has a special role in aortic valve functionality and any variation may influence the aortic root dynamics: the left ventricle outflow tract, the annulus, the leaflets, the commissures, the Valsalva sinuses, and the sinotubular junction.

Engineering and biotechnology have been aimed at critical analysis of the main features of the human aortic valve in an effort to incorporate these qualities into the design of valve prostheses.

In stented valves the aortic root dynamics are not preserved, so performance and potential durability are more related to structural design. The major potential advantage of stentless valves is to achieve the ideal hemodynamic performance of the normal human valve showing significant superiority in peak and mean gradients, as well as cardiac output, compared to stented valves and very similar to homografts, but the prognostic value of these data is still to be proved.

Durability remains a primary concern for any bioprosthesis, which is even more relevant in the stentless world where technical implantation issues and complexity at reoperation should be considered.

The design of stentless valves as well as their mechanical wear and stress absorption properties should determine (and for many reasons in most cases had not) better leaflets preservation and enhanced durability. Furthermore, and perhaps even more important, stentless valve implantation techniques are generally more demanding, less reproducible and standardized, and dramatically dependent on the surgeon’s skill and experience.

Well aware of the advantages of being placed upon the shoulders of our predecessors in the stentless world, in 2004 we tried to rethink the stentless concept in the context of aortic root physiological aspects playing a paramount role in dynamics and potential durability. The ideal stentless valve should be “truly” stentless and flexible without any fabric or synthetic material as cloth or reinforcement limiting pliability and contributing to an unforeseeable variable in the degenerative process toward rigidity and calcification. Moreover both annulus and STJ should not be fixed by rigid material, preserving physiologic root dynamics and providing only new leaflets to replace the pathological ones. Then valve insertion into the aortic root should be easy, fast, and reproducible.

These concepts constituted the theoretical basis for the development of the Freedom SOLO stentless valve (Livanova): three bovine pericardial leaflets implanted in a supra-annular position with a single suture line. Minimal invasiveness and easy and fast implantability have been a successful strategy when high-risk aged patients are concerned, while valve durability, SVD rates, and long-term complications established by the test of time will play the determining role to expand indications in a younger and healthier population.

In the meantime, attentive and careful trials of all possible alternatives toward a “native-like” aortic valve with very long-term (more than 20 years) durability should be continued and evaluated to implement data to guide future indications.

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References

  1. Hurley PJ, Lowe JB, Barratt-Boyes BG. Debridement-valvotomy for aortic stenosis in adults: a follow-up of 76 patients. Thorax. 1967;22:314–9.

    Article  CAS  Google Scholar 

  2. Kirklin JW, Mankin HT. Open operation in the treatment of calcific aortic stenosis. Circulation. 1960;21:578–86.

    Article  CAS  Google Scholar 

  3. Bahnson HT, Spencer FC, Busse EF, et al. Cusp replacement and coronary artery perfusion in open operations on the aortic valve. Ann Surg. 1960;152:494–503.

    CAS  PubMed  PubMed Central  Google Scholar 

  4. Hufnagel CA, Conrad PW. The direct approach for the correction of aortic insufficiency. JAMA. 1961;178:275–9.

    Article  CAS  Google Scholar 

  5. McGoon DC, Mankin HT, Kirklin JW. Results of open heart operation for acquired aortic valve disease. J Thorac Cardiovasc Surg. 1963;45:47.

    Google Scholar 

  6. McGoon DC. Prosthetic reconstruction of the aortic valve. Mayo Clin Proc. 1961;36:88.

    Google Scholar 

  7. Murray G. Homologous aortic valve segment transplant as surgical treatment for aortic and mitral insufficiency. Angiology. 1956;7:466–71.

    Article  CAS  Google Scholar 

  8. Barratt-Boyes BG. Homograft aortic valve replacement in aortic incompetence and stenosis. Thorax. 1964;19:131–50.

    Article  CAS  Google Scholar 

  9. Duran CG, Gunning AJ. A method for placing a total homologous aortic valve in the subcoronary position. Lancet. 1962;8(2):488–9.

    Article  Google Scholar 

  10. Ross DN. Homograft replacement of the aortic valve. Lancet. 1962;8:487.

    Article  Google Scholar 

  11. Hoeksima TD, Titus JL, Giuliani ER, et al. Early results of use of homografts for replacement of aortic valve in man. Circulation. 1967;35:S9–14.

    Google Scholar 

  12. Karp RB, Kirklin JW. Replacement of diseased aortic valves with homografts. Ann Surg. 1969;169:921–6.

    Article  CAS  Google Scholar 

  13. Pacifico AD, Karp RB, Kirklin JW. Homografts for replacement of the aortic valve. Circulation. 1972;45:S36–43.

    Google Scholar 

  14. Barratt-Boyes BG. A method for preparing and inserting a homograft aortic valve. Br J Surg. 1965;52:847–56.

    Article  CAS  Google Scholar 

  15. Barratt-Boyes BG. Long-term follow-up of aortic valvar graft. Br Heart J. 1971;33:S60–5.

    Article  Google Scholar 

  16. Ross DN. Aortic-valve replacement. Lancet. 1966;2:461–3.

    Article  CAS  Google Scholar 

  17. Donaldson RM, Ross DM. Homograft aortic root replacement for complicated prosthetic valve endocarditis. Circulation. 1984;70:178–81.

    Article  Google Scholar 

  18. Gula G, Pomerance A, Bennet M, et al. Homograft replacement of aortic valve and ascending aorta in patient with non-specific giant cell aortitis. Br Heart J. 1977;39:581–5.

    Article  CAS  Google Scholar 

  19. Ross DN, Martelli V, Wain WH. Allograft and autograft valves used for aortic valve replacement. In: Ionescu MI, editor. Tissue heart valves. London: Butterworth; 1979.

    Google Scholar 

  20. Harken DE, Soroff HS, Taylor WJ, et al. Partial and complete prostheses in aortic insufficiency. J Thorac Cardiovasc Surg. 1960;40:744–62.

    CAS  PubMed  Google Scholar 

  21. Starr A, Edwards ML, McCord CW, et al. Aortic replacement: clinical experience with a semirigid ball-valve prosthesis. Circulation. 1963;27:779.

    Article  Google Scholar 

  22. Silberman S, Shaheen J, Fink D, et al. Comparison of exercise hemodynamics among nonstented aortic bioprosthesis, mechanical valves, and normal native aortic valves. J Card Surg. 1998;13:412–6.

    Article  CAS  Google Scholar 

  23. Akins CW. Results with mechanical cardiac valvular prostheses. Ann Thorac Surg. 1995;60:1836–44.

    Article  CAS  Google Scholar 

  24. Edmunds LH. Evolution of prosthetic heart valves. Am Heart J. 2001;141:849–55.

    Article  Google Scholar 

  25. Fann JI, Miller DC. Porcine valves: Hancock and Carpentier-Edwards aortic prostheses. Semin Thorac Cardiovasc Surg. 1996;8:259–68.

    CAS  PubMed  Google Scholar 

  26. Binet JP, Duran CG, Carpenter A, et al. Heterologous aortic valve transplantation. Lancet. 1965;18:1275.

    Article  Google Scholar 

  27. Carpentier A, Lemaigre G, Robert L, et al. Biological factors affecting long-term results of valvular heterografts. J Thorac Cardiovasc Surg. 1969;58:467–83.

    CAS  PubMed  Google Scholar 

  28. Ionescu MI, Pakrashi BC, Holden MP, et al. Results of aortic valve replacement with frame-supported fascia lata and pericardial grafts. J Thorac Cardiovasc Surg. 1972;64:340–53.

    CAS  PubMed  Google Scholar 

  29. Mayne AS, Christie GW, Smaill BH, et al. An assessment of the mechanical properties of leaflets from four second-generation porcine bioprostheses with biaxial testing techniques. J Thorac Cardiovasc Surg. 1989;98:170–80.

    CAS  PubMed  Google Scholar 

  30. Lawford PV, Black MM, Drury PJ, et al. The in vivo durability of bioprosthetic heart valves-modes of failure observed in explanted valves. Eng Med. 1987;16:95–103.

    Article  CAS  Google Scholar 

  31. David TE, Pollick C, Bos J. Aortic valve replacement with stentless porcine aortic bioprosthesis. J Thorac Cardiovasc Surg. 1990;99:113–8.

    CAS  PubMed  Google Scholar 

  32. O’Brien MF, Finney RS, Stafford EG, et al. Root replacement for all allograft aortic valves: preferred technique or too radical? Ann Thorac Surg. 1995;60:S87–91.

    Article  Google Scholar 

  33. Desai ND, Merin O, Cohen GN, et al. Long-term results of aortic valve replacement with the St. Jude Toronto stentless porcine valve. Ann Thorac Surg. 2004;78:2076–83.

    Article  Google Scholar 

  34. Thubrikar MJ. The aortic valve. Boca Raton, FL: CRC Press; 1990.

    Google Scholar 

  35. Cheng A, Dagum P, Miller DC. Aortic root dynamics and surgery: from craft to science. Philos Trans R Soc Lond Ser B Biol Sci. 2007;362:1407–19.

    Article  Google Scholar 

  36. Dagum P, Green GR, Nistal FJ, et al. Deformational dynamics of the aortic root: modes and physiologic determinants. Circulation. 1999;100:S54–62.

    Google Scholar 

  37. O’Brien MF. Implantation technique of the Cryolife-O’Brien stentless xenograft aortic valve: the simple, rapid, and correct way to implant and the errors to avoid. Semin Thorac Cardiovasc Surg. 1999;11:S121–5.

    Google Scholar 

  38. Petracek MR. Assessing options for the small aortic root. J Heart Valve Dis. 2002;11:S50–5.

    PubMed  Google Scholar 

  39. Palka P, Harrocks S, Lange A, et al. Primary aortic valve replacement with cryopreserved aortic allograft: an echocardiographic follow-up study of 570 patients. Circulation. 2002;105:61–6.

    Article  Google Scholar 

  40. Jamieson WR. Quantification of haemodynamic performance of stented and stentless aortic bioprostheses and potential influence on survival. Heart Lung Circ. 2003;12:149–56.

    Article  Google Scholar 

  41. Vesely I. Analysis of the Medtronic intact bioprosthetic valve. Effects of “zero-pressure” fixation. J Thorac Cardiovasc Surg. 1991;101:90–9.

    CAS  PubMed  Google Scholar 

  42. Christie GW, Gross JF, Eberhardt CE. Fatigue-induced changes to the biaxial mechanical properties of glutaraldehyde-fixed porcine aortic valve leaflets. Semin Thorac Cardiovasc Surg. 1999;11:S201–5.

    Google Scholar 

  43. Schoen FJ, Levy RJ. Calcification of tissue heart valve substitutes: progress toward understanding and prevention. Ann Thorac Surg. 2005;79:1072–80.

    Article  Google Scholar 

  44. Del Rizzo DF, Goldman BS, Christakis GT, et al. Hemodynamic benefits of the Toronto stentless valve. J Thorac Cardiovasc Surg. 1996;112:1431–45.

    Article  Google Scholar 

  45. Jin XY, Zhang ZM, Gibson DG, et al. Effects of valve substitute on changes in left ventricular function and hypertrophy after aortic valve replacement. Ann Thorac Surg. 1996;62:683–90.

    Article  CAS  Google Scholar 

  46. Westaby S, Jin XY, Katsumata T, et al. Valve replacement with a stentless bioprosthesis: versatility of the porcine aortic root. J Thorac Cardiovasc Surg. 1998;116:477–84.

    Article  CAS  Google Scholar 

  47. Cohen G, Christakis GT, Buth KJ, et al. Early experience with stentless versus stented valves. Circulation. 1997;96:S76–82.

    Article  Google Scholar 

  48. Cohen G, Christakis GT, Joyner CD, et al. Are stentless valves hemodynamically superior to stented valves? A prospective randomized trial. Ann Thorac Surg. 2002;73:767–75.

    Article  Google Scholar 

  49. De Paulis R, Sommariva L, Colagrande L, et al. Regression of left ventricular hypertrophy after aortic valve replacement for aortic stenosis with different valve substitutes. J Thorac Cardiovasc Surg. 1998;116:590–8.

    Article  Google Scholar 

  50. Borger MA, Carson SM, Ivanov J, et al. Stentless aortic valves are hemodynamically superior to stented valves during mid-term follow-up: a large retrospective study. Ann Thorac Surg. 2005;80:2180–5.

    Article  Google Scholar 

  51. Lehmann S, Walther T, Kempfert J, et al. Stentless versus conventional xenograft aortic valve replacement: midterm results of a prospectively randomized trial. Ann Thorac Surg. 2007;84:467–72.

    Article  Google Scholar 

  52. Maselli D, Pizio R, Bruno LP, et al. Left ventricular mass reduction after aortic valve replacement: homografts, stentless and stented valves. Ann Thorac Surg. 1999;67:966–71.

    Article  CAS  Google Scholar 

  53. Williams RJ, Muir DF, Pathi V, et al. Randomized controlled trial of stented and stentless aortic bioprotheses: hemodynamic performance at 3 years. Semin Thorac Cardiovasc Surg. 1999;11:S93–7.

    Google Scholar 

  54. Walther T, Falk V, Langebartels G, et al. Prospectively randomized evaluation of stentless versus conventional biological aortic valves: impact on early regression of left ventricular hypertrophy. Circulation. 1999;100:S6–10.

    Google Scholar 

  55. Yun KL, Sintek CF, Fletcher AD, et al. Aortic valve replacement with the freestyle stentless bioprosthesis: five-year experience. Circulation. 1999;100:S17–23.

    Google Scholar 

  56. B K, Vijayalakshmi K, Thornley AR, et al. Meta-analysis of valve hemodynamics and left ventricular mass regression for stentless versus stented aortic valves. Ann Thorac Surg. 2007;84:73–8.

    Article  Google Scholar 

  57. Gulbins H, Reichenspurner H. Which patients benefit from stentless aortic valve replacement? Ann Thorac Surg. 2009;88:2061–8.

    Article  Google Scholar 

  58. Collinson J, Flather M, Coats AJ, et al. Influence of valve prosthesis type on the recovery of ventricular dysfunction and subendocardial ischaemia following valve replacement for aortic stenosis. Int J Cardiol. 2004;97:535–41.

    Article  Google Scholar 

  59. Bevilacqua S, Gianetti J, Ripoli A, et al. Aortic valve disease with severe ventricular dysfunction: stentless valve for better recovery. Ann Thorac Surg. 2002;74:2016–21.

    Article  Google Scholar 

  60. David TE, Puschmann R, Ivanov J, et al. Aortic valve replacement with stentless and stented porcine valves: a case-match study. J Thorac Cardiovasc Surg. 1998;116:236–41.

    Article  CAS  Google Scholar 

  61. Westaby S, Horton M, Jin XY, et al. Survival advantage of stentless aortic bioprostheses. Ann Thorac Surg. 2000;70:785–90.

    Article  CAS  Google Scholar 

  62. Tamim M, Bové T, Van Belleghem Y, et al. Stentless vs. stented aortic valve replacement: left ventricular mass regression. Asian Cardiovasc Thorac Ann. 2005;13(2):112–8.

    Article  Google Scholar 

  63. Silberman S, Shaheen J, Merin O, et al. Exercise hemodynamics of aortic prostheses: comparison between stentless bioprostheses and mechanical valves. Ann Thorac Surg. 2001;72:1217–21.

    Article  CAS  Google Scholar 

  64. Fries R, Wendler O, Schieffer H, et al. Comparative rest and exercise hemodynamics of 23-mm stentless versus 23-mm stented aortic bioprostheses. Ann Thorac Surg. 2000;69:817–22.

    Article  CAS  Google Scholar 

  65. Morsy S, Zahran M, Usama M, et al. Hemodynamic performance of stentless porcine bioprosthesis and mechanical bileaflet prosthesis using dobutamine stress echocardiography. Semin Thorac Cardiovasc Surg. 2001;13:S129–35.

    Google Scholar 

  66. Blais C, Dumesnil JG, Baillot R, et al. Impact of valve prosthesis-patient mismatch on short-term mortality after aortic valve replacement. Circulation. 2003;108:983–8.

    Article  Google Scholar 

  67. O’Brien MF, Gardner MA, Garlick B, et al. CryoLife-O’Brien stentless valve: 10-year results of 402 implants. Ann Thorac Surg. 2005;79:757–66.

    Article  Google Scholar 

  68. Bach DS, Cartier PC, Kon ND, et al. Impact of implant technique following freestyle stentless aortic valve replacement. Ann Thorac Surg. 2002;74:1107–13.

    Article  Google Scholar 

  69. Wendler O, Dzindzibadze V, Langer F, et al. Aortic valve replacement with a stentless bioprosthesis using the full-root technique. Thorac Cardiovasc Surg. 2001;49:361–4.

    Article  CAS  Google Scholar 

  70. Stanger O, Bleuel I, Gisler F, et al. The freedom Solo pericardial stentless valve: single-center experience, outcomes, and long-term durability. J Thorac Cardiovasc Surg. 2015;150:70–7.

    Article  Google Scholar 

  71. Repossini A, Kotelnikov I, Bouchikhi R, et al. Single-suture line placement of a pericardial stentless valve. J Thorac Cardiovasc Surg. 2005;130:1265–9.

    Article  Google Scholar 

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Authors and Affiliations

  1. Cardiac Surgery, University of Brescia Medical School, Brescia, Italy

    Alberto Repossini

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  1. Alberto Repossini
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Editors and Affiliations

  1. Fmr Royal Brompton Hospital, London, UK

    Olaf H. Stanger

  2. Royal Brompton Hospital, London, UK

    John R. Pepper

  3. Heart and Vascular Institute, Cleveland Clinic, Cleveland, OH, USA

    Lars G. Svensson

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Repossini, A. (2019). The Stentless Valve Concept. In: Stanger, O., Pepper, J., Svensson, L. (eds) Surgical Management of Aortic Pathology. Springer, Vienna. https://doi.org/10.1007/978-3-7091-4874-7_47

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  • DOI: https://doi.org/10.1007/978-3-7091-4874-7_47

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