Aortic valve replacement with stentless porcine bioprostheses

The implantation of stentless porcine valves (SPVs) is technically more demanding than implantation of stented bioprosthetic valves. Implantation of the Toronto SPV bioprosthesis requires an understanding of the relationships between the leaflets and the aortic annulus and sinotubular junction. In addition to proper alignment of the three commissures within the aortic root, the diameter of sinotubular junction should not exceed the external diameter of the porcine aortic valve after completion of the operation. The Medtronic Freestyle porcine aortic root bioprosthesis can be used for subcoronary implantation as well as for aortic root replacement. Degenerative calcification of a tricuspid aortic valve is the most common cause of aortic valve disease in older patients. Implantation of stentless valves in the subcoronary position is usually feasible because the geometry of the aortic root is well maintained in these patients. The bicuspid aortic valve is the second most common cause of aortic valve disease in older patients and the most common in younger patients. These patients frequently have dilated aortic root, and the Medtronic Freestyle bioprosthesis is ideal for implantation using the root inclusion technique, Stentless porcine bioprostheses are minimally obstructive and associated with low mean systolic gradients. In addition, they have better hemodynamic performance during exercise than stented bioprostheses. For these reasons, patient-prosthesis mismatch has not been described with stentless valves. Left ventricular function after aortic valve replacement appears to be better with stentless than with stented bioprostheses. Comparative, nonrandomized studies of aortic valve replacement with stented and stentless valves suggest that the risk of cardiac death is reduced with stentless valves and the rates of valve-related complications also appear to be lower. What remains unknown is whether stentless valves are more durable than stented ones.