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An annular plication strategy used three horizontal mattress sutures at interleaflet triangles to reduce annular size for Perceval XL use. A totally endoscopic approach via right mini-thoracotomy was performed, followed by echocardiographic confirmation of excellent positioning and no paravalvular leak. The patient recovered uneventfully and remained asymptomatic with good prosthesis function at 3-year follow-up.",{"@graph":69,"@context":122},[70,84,105],{"@type":71,"itemListElement":72},"BreadcrumbList",[73,77,79,82],{"item":74,"name":75,"@type":76,"position":8},"https://docshare.wps.com","Home","ListItem",{"item":78,"name":9,"@type":76,"position":14},"https://docshare.wps.com/document/",{"item":80,"name":35,"@type":76,"position":81},"https://docshare.wps.com/document/healthcare/",3,{"item":83,"name":65,"@type":76,"position":19},"https://docshare.wps.com/document/sutureless-aortic-valve-replacement-with-annular-plication-technique-in-an-oversized-annulus/459124/",{"url":83,"name":65,"@type":85,"image":86,"author":91,"headline":65,"publisher":94,"fileFormat":97,"inLanguage":63,"description":67,"dateModified":98,"datePublished":99,"encodingFormat":97,"isAccessibleForFree":100,"interactionStatistic":101},"DigitalDocument",{"url":87,"@type":88,"width":89,"height":90},"https://docshare.wps.com/thumbnails/sutureless-aortic-valve-replacement-with-annular-plication-technique-in-an-oversized-annulus/459124.png","ImageObject",300,407,{"name":92,"@type":93},"dawugda","Person",{"url":74,"name":95,"@type":96},"DocShare","Organization","application/pdf","2026-11-08","2026-09-30",true,{"@type":102,"interactionType":103,"userInteractionCount":14},"InteractionCounter",{"@type":104},"ViewAction",{"@type":106,"mainEntity":107},"FAQPage",[108,114,118],{"name":109,"@type":110,"acceptedAnswer":111},"What patient and valve findings required the annular plication approach?","Question",{"text":112,"@type":113},"The case involved a 72-year-old man with symptomatic severe aortic regurgitation, moderate aortic stenosis, and an annular diameter of 30 mm, exceeding the recommended range for Perceval implantation.","Answer",{"name":115,"@type":110,"acceptedAnswer":116},"How does the annular plication technique enable Perceval XL implantation in an oversized annulus?",{"text":117,"@type":113},"Three U-shaped horizontal mattress sutures are placed at all interleaflet triangles to reduce annular size (approximately 6.0 mm at each triangle), allowing implantation of the Perceval XL valve.",{"name":119,"@type":110,"acceptedAnswer":120},"What outcomes were reported after surgery and during follow-up?",{"text":121,"@type":113},"Postoperative echocardiography showed excellent prosthesis function with no paravalvular leak. 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Sutureless Aortic Valve Replacement with Annular Plication Technique in an Oversized Annulus. Interdiscip CardioVasc Thorac Surg 2025; doi:10.1093/icvts/ivaf287.  \nSutureless Aortic Valve Replacement with Annular Plication Technique in an Oversized Annulus  \nShota Inoue1; Chikara Ueki1; Minoru Tabata  􀀃 ,1,2  \n1 Department of Cardiovascular Surgery, Toranomon Hospital, Tokyo105-8470, Japan  \n2 Department of Cardiovascular Surgery, Juntendo University School of Medicine, Tokyo 113-8421 , Japan  \n􀀃 Corresponding author. Department of Cardiovascular Surgery, Juntendo University School of Medicine, 2-1-1 Hongo, Bunkyo-ku, Tokyo 113-8431, Japan ([minorutabata@juntendo.ac.jp](minorutabata@juntendo.ac.jp)).  \nReceived: August 25, 2025; Revised: November 6, 2025; Accepted: November 18, 2025  \nAbstract  \nWe present the case of a 72-year-old man with symptomatic severe aortic regurgitation and moderate aortic stenosis, and an annular diameter of 30 mm, exceeding the recommended range for sutureless Perceval valve implantation. To reduce the annular size to allow implantation of the Perceval XL valve, an annular plication technique was employed, involving three horizontal mattress sutures placed atthe interleaflet triangles. A totally endoscopic approach via right mini-thoracotomy was utilized. Postoperative echocardiography confirmed excellent valve positioning and no paravalvular leak. The patient recovered uneventfully and remained asymptomatic with good prosthesis function at the 3-year follow-up. This case demonstrated that annular plication enables the safe use of the Perceval valve inpatients with a mildly oversized annulus and may expand its applicability in minimally invasive settings.  \nKeywords: aortic valve; annular plication technique; sutureless valve; minimally invasive cardiac surgery.  \nINTRODUCTION  \nThe Perceval valve (Corcym, Saluggia, Italy), known for its sutureless design, has been widely used in minimally invasive cardiac surgery due to reduced aortic cross-clamp time. However, its use is limited to annular diameters of ≤27 mm. This report describes the annular plication technique for Perceval valve implantation in patients with a mildly oversized annulus.  \nSURGICAL TECHNIQUE (VIDEO 1)  \nA 72-year-old man with symptomatic severe aortic regurgitation and moderate aortic stenosis was considered a candidate for surgical aortic valve replacement. At that time, an automated suture fastening device was not available in the country; therefore, to facilitate implantation via a totally endoscopic approach, the Perceval sutureless valve, offering superior implantability compared with a conventional stented valve, was preferred. Preoperative cardiac computed tomography (CT) revealed aright-noncoronary fused type 1 bicuspid aortic valve with mild annular dilatation (diameter, 30 mm; circumference, 98.6 mm), without significant dilatation of the ascending aorta (32.1 mm) or the sinus of Valsalva (37.6 × 36.0 × 41.0 mm). The largest Perceval valve (XL) is designed for annular diameters ranging from 25 to 27 mm. To achieve a median annular diameter of 26 mm, the circumference needed to be reduced to 81.6 mm. Given the patient’s body size (body surface area was 1.8 m2), we  \nanticipated that sufficient effective orifice area (EOA) could be maintained even after annular plication. Therefore, to enable implantation of the Perceval valve, we planned to perform annular plication to reduce the annular size appropriately.  \nThe procedure was performed using a totally endoscopic approach through a 3-cm right anterior mini-thoracotomy in the second intercostal space, without a rib spreader, using a 5-mm endoscopic port. A 4 K 30􀀎 angled endoscope was employed. Cardio","cbCaik5Qyd7B4vPD","https://ap.wps.com/l/cbCaik5Qyd7B4vPD","pdf",537154,"English","# Abstract\n# Introduction\n# Surgical Technique (Video 1)","[{\"question\":\"What patient and valve findings required the annular plication approach?\",\"answer\":\"The case involved a 72-year-old man with symptomatic severe aortic regurgitation, moderate aortic stenosis, and an annular diameter of 30 mm, exceeding the recommended range for Perceval implantation.\"},{\"question\":\"How does the annular plication technique enable Perceval XL implantation in an oversized annulus?\",\"answer\":\"Three U-shaped horizontal mattress sutures are placed at all interleaflet triangles to reduce annular size (approximately 6.0 mm at each triangle), allowing implantation of the Perceval XL valve.\"},{\"question\":\"What outcomes were reported after surgery and during follow-up?\",\"answer\":\"Postoperative echocardiography showed excellent prosthesis function with no paravalvular leak. The patient recovered uneventfully and remained asymptomatic with good prosthesis function at the 3-year follow-up.\"}]","Sutureless Aortic Valve Replacement with Annular Plication Technique in an Oversized Annulus | PDF"]