INTUITY Elite valve (Edwards Life Sciences, Irvine, CA, USA)
This system can be used in both conventional and minimally invasive surgeries, and it is covered by insurance even for patients on dialysis and for whom TAVR is not covered by insurance in Japan. The INTUITY Elite valve is designed to be compatible with conventional SAVR. However, the size of the delivery system is usually larger than the size of the prosthetic valve; hence, it may not pass through the sinotubular junction, and surgeons may have to choose smaller valves, which could increase the risk of paravalvular leakage. Conversely, bundle branch block or complete atrioventricular blocks can be induced by any resistance caused by the passage of the prosthetic valve through the annulus. Selecting the appropriate valve size is a critical step in the implantation of the INTUITY elite valve. How the valve sits on the annulus and how the inflow frame expands sub-annularly should be considered when selecting an appropriate sized valve.
We always used both the supra-and subannular sizing procedures. We used Magna Ease sizers to define the right valve diameter. We always avoided forcefully passing the valve through the annulus. Furthermore, we selected a size that we felt could effortlessly pass through the aortic annulus. If the measurement of the annulus is between two valve sizes, we always choose the smaller-sized valve.
If we choose a smaller sized valve, we may find a gap in the commissure (Figure 2A). It is essential to check for this gap to determine the location of the inserted prosthetic valve in the commissure. From our experience thus far, we have found that a gap more frequently occurs in the right coronary cusp (RCC)-noncoronary cusp (NCC) commissure than in the left coronary cusp (LCC)-RCC commissure. Even when aligned with the nadir, the prosthetic valve is located at the supra-annular position as the height of top of the commissure is greater than the INTUITY prosthetic valve’s height; however, the valve is still in the infra-annular position at the commissure.