The Critical Role of Presettable and Expandable Artificial Surgical Valves in the Lifetime Management of Valvular Heart Disease

Abstract

With the trend of younger patients undergoing surgical valve replacement and increased life expectancy, how to account for subsequent therapies during the initial valve replacement has become a pivotal focus in the lifetime management of valvular heart disease. In China, a significant proportion of patients requiring aortic valve replacement present with small aortic roots. Beyond intraoperative root enlargement techniques, implanting surgical valves with optimal orifice areas and annulus diameters tailored to these patients is critical for both postoperative outcomes and future therapeutic interventions. The pre-settable valve is designed specifically for patients with small aortic roots. Its unique annulus-stent configuration and stent-leaflet suturing technique allow the valve to expand by 1–2 sizes post-implantation. During surgery, the valve is sutured in a reduced, smaller configuration. After being implanted, the annulus diameter could be expande by 1–2 sizes under balloon dilation, while the expanded stent-leaflets structure is in normal functional morphology. In contrast, the expandable valve addresses the need for sequential therapies following surgical valve replacement. Its purpose is to enlarge the valve area to accommodate a same-diameter transcatheter valve-in-valve (ViV) implantation. Initially implanted in its functional state, this valve can be expanded by one size under high-pressure balloon dilation (>5 atm) years later if degeneration or failure occurs. A transcatheter valve can then be deployed within the expanded surgical valve, eliminating the need for repeat open-heart surgery. This approach significantly reduces patient trauma and extends the expected lifespan of bioprosthetic valve replacements. Both designs aim to achieve larger effective orifice areas. The presettable valve operates normally after annulus expansion, while the expandable valve’s expansion facilitates subsequent transcatheter ViV implantation. Animal studies and preliminary clinical trials have demonstrated promising outcomes, suggesting these innovations will profoundly impact the sequential management of valvular heart disease under a lifetime management paradigm.