title: The use of a rigid instrument prior to stentless valve implantation facilitates correct alignment of the prosthesis and native aortic valve apparatus.
abstract: OBJECTIVE
  When correctly seated in the aortic position, stentless valves are associated with a relatively low transvalvular gradient. This leads to regression of left ventricular hypertrophy and long-term survival. The alleged complexity of stentless valve implantation has led to a preference for stented/mechanical prostheses. Here, the use of a rigid instrument to prevent technical complications after stentless valve implantation was investigated.
  
  
  METHODS
  Aortic valve replacement was performed in 75 patients (44 males, 31 females; mean age 72 years; range: 33-89 years) using the Toronto Stentless Porcine Valve (TSPV). Among patients, 37% had coronary artery bypass grafting and 3% mitral valve replacement. Valve size was either 23-25 mm (65%) or 21 mm (35%) and determined by sinotubular junction diameter. A rigid instrument was designed that mimics actual valve shape and accounted for valve dimensional variations and asymmetries on a size-by-size basis. The instrument was used to mark the site of the inflow and outflow suture lines and to determine orientation of the muscle bar on the prosthetic valve. Intraoperative transesophageal echocardiography was used to monitor all patients.
  
  
  RESULTS
  The mean intraoperative mean systolic peak pressure gradient (all valves) was 18.35 +/- 9.41 mmHg; there were no paravalvular leaks. Among patients, 22% had central trace aortic insufficiency, and one patient developed renal failure that required hemodialysis. There were no cerebral vascular accidents/infections, but one perioperative myocardial infarction occurred. There were four postoperative deaths, but none was valve-related.
  
  
  CONCLUSIONS
  Routine use of the instrument may avoid many risks during TSPV implantation. The device permits the surgeon to accommodate variation in the angle between the coronary ostia, as well as in the distance between these ostia and the native annulus.
authors.affiliation: Division of Cardiothoracic Surgery, Albert Einstein Medical Center--Jefferson Health System, Philadelphia, Pennsylvania 19141, USA.
authors.forename: Robert L
authors.initials: RL
authors.lastname: Quigley
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000401:mortality / Q000601:surgery; D001794:Blood Pressure / Q000502:physiology; D001807:Blood Vessel Prosthesis; D001026:Coronary Artery Bypass; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000295:instrumentation*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011183:Postoperative Complications / Q000209:etiology / Q000401:mortality / Q000628:therapy; D011474:Prosthesis Design; D006435:Renal Dialysis; D015607:Stents; D016019:Survival Analysis; D016896:Treatment Outcome