Abbreviations, Acronyms & Symbols
CT	= Computed tomography
STJ	= Sinotubular junction

Implantation of sutureless aortic valves enables quicker procedures, thereby reducing surgical times and associated risks^[1]. However, historically, their application has been limited by the presence of concomitant aortic root and sinotubular junction (STJ) aneurysms, necessitating a STJ/annulus ratio < 1.3^[2]. In this paper, we highlight the challenging application of a sutureless aortic valve in a patient with a severely calcified ascending aortic aneurysm and concomitant coronary artery disease. This case underscores the feasibility of utilizing sutureless valve technology in complex aortic pathology, which expands the potential indications for its use in cases where it has historically controverted.

A 70-year-old female patient, with a medical history including stage IV kidney dysfunction, hypertension, type II diabetes, former smoking habits, and a previous stroke resulting in residual mild right hemiparesis, was transferred to our institution due to symptomatic severe aortic insufficiency in a New York Heart Association III/IV status, evidenced by transthoracic echocardiography with a regurgitant jet occupying 60% of the left ventricular outflow tract and a left ventricular ejection fraction of 55%. Preoperative computed tomography (CT) scan revealed a porcelain aorta with concurrent aneurysms of the ascending portion (60 mm) and proximal arch (48 mm), while the aortic root appeared normal (Figure 1A). Coronary angiography indicated 80% stenosis in the main trunk and 70% stenosis in the proximal left anterior descending artery (Figure 1B). The patient's case was discussed by a Heart Team, and a percutaneous strategy was declined due to the presence of an ascending aortic aneurysm and left main coronary artery stenosis. The study was approved by the hospital ethics committee (SSMOriente190324) and informed consent was obtained.

Fig. 1

The use of rapid deployment aortic valves had been contraindicated in patients with root and ascending aortic aneurysms due to concerns regarding the anchor system^[3]. Nonetheless, a handful of published cases have demonstrated the feasibility and excellent outcomes of this approach^[2-5]. This case report highlights several key points. Sutureless valves have been shown to reduce normal cardiopulmonary bypass times by up to 40%, making them a valuable tool in the treatment of severely ill patients^[4]. These saved minutes can be invaluable, especially in combined procedures. The optimal sequence for valve deployment may vary depending on the patient's specific situation. One approach involves creating a new STJ with aortic-Dacron® anastomosis before valve deployment. Alternatively, starting with the posterior wall of the aortic-Dacron® anastomosis also allows for proper positioning of the valve before completing the anterior portion of the anastomosis in usual fashion.

On the other hand, a porcelain aorta is a predictor of mortality and stroke and presents additional challenges for surgical intervention, including arterial cannulation and aortic clamping^[6]. Epiaortic echocardiography is an invaluable tool at time of cannulation to find the perfect spot in severe aortic calcification. Planning for cerebral protection and avoiding aortic cross-clamping are emphasized to reduce the risk of distal embolization.

While a limited number of cases have been published, this case underscores the importance of rapid valve deployment in challenging patients and its feasibility alongside concomitant ascending aortic replacement without valve migration. Moreover, dealing with a porcelain aorta adds complexity and highlights the importance of meticulous planning and teamwork. Nevertheless, larger series are still needed to confirm the efficacy of sutureless valves in such scenarios.