Transcatheter Aortic Valve Replacement in a Perceval Valve: Pitfalls, Tips, and Outcomes.

The Perceval valve (Corcym, Milan, Italy) is the only sutureless surgical aortic valve replacement (SAVR) on the market. With widespread use of the Perceval valve, valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) have been increasingly reported. While the Perceval provides a favorable initial valve choice for ViV TAVR, specific challenges exist. The Perceval stent design poses a risk of the guidewire and catheter becoming misplaced between the valve stent and the aortic wall which can be mitigated by confirming wire location on multiple imaging views, using a stiff pigtail catheter, and advancing a wire through a septal puncture and antegrade through the valve and snare the wire to guide it into the ventricle. TAVR valve positioning should aim to align the inflow of the TAVR valve with the inflow of the Perceval valve for self-expanding valves. For balloon expandable valves, the outflow of the TAVR should be aligned proximally to the distal stent taper of the Perceval. Finally, coronary obstruction risk should be considered on preoperative imaging with intraoperative wire access, prophylactic snorkel stent placement, or leaflet modification techniques to mitigate the risk of coronary obstruction in high-risk patients. Previously published literature has demonstrated high rates of successful ViV TAVR in Perceval. The outcomes have also been favorable with low rates of major bleeding, coronary obstruction, annular rupture, and mortality. Future studies should aim to better characterize aortic root anatomy following SAVR to determine the suitability of specific surgical valves for future ViV TAVR.