A challenging Perceval valve implantation during concomitant mitral valve replacement with a bioprosthesis.

In this video tutorial, we emphasize the main pitfalls in adequate sizing and expansion of the Perceval valve during a concomitant mitral valve replacement with a bioprosthetic. Following mitral valve replacement with a tissue-stented bioprosthesis, a transverse aortotomy was performed at 3 cm above the level of the aortic annulus. Three guiding sutures were then placed 120° apart in each valve sinus, 2-3 mm below the leaflet hinge point. The commissural struts of the mitral prosthesis can be seen in the aortic annulus. This positioning minimizes any potential protrusion in the left ventricular outflow tract.  Next, sizing of the Perceval was performed. The small transparent sizer fit nicely; however, a clear gap at the annulus could be appreciated with the small white sizer. The medium transparent sizer was then utilized, and it fit nicely; however, the medium white sizer was not able to pass through the aortic annulus. Given the gap present with the small sizer, we opted for a medium-size prosthesis. A medium Perceval prosthesis was parachuted into the aortic annulus with the help of the guiding sutures and the valve was deployed. Next, balloon expansion of the stent was performed. Given the potential concern of under-expansion of the stent, we opted for a longer dilatation at 4 atm for 1 min rather than the usual 30 sec. The aortotomy was then closed.