Sutureless Aortic Valve Replacement: First-Year Single-Center Experience

Right anterior mini-thoracotomy aortic valve replacement versus transcatheter aortic valve implantation in octogenarians: a single-center retrospective study

BACKGROUND

The aim of this study was to compare the early outcomes of octogenarians undergoing minimally invasive right anterior mini-thoracotomy aortic valve replacement (RAT-AVR) with those undergoing transcatheter aortic valve implantation (TAVI) for aortic valve disease.

METHODS

In this single-center retrospective study, data were collected from octogenarians before and after RAT-AVR and TAVI between January 2021 and July 2022. Short-term outcomes, including the length of hospital stay, in-hospital mortality, all-cause mortality, and other major postoperative complications, were compared and analyzed.

RESULTS

There were no significant differences in in-hospital mortality, stroke, acute kidney dysfunction requiring renal replacement therapy, length of intensive care unit stay, or length of hospital stay. However, the TAVI group had a higher incidence of permanent pacemaker insertion (10% vs. 0%, p=0.54) and paravalvular leaks (75% vs. 0%, p<0.001).

CONCLUSION

In the present study on octogenarians, both TAVI and RAT-AVR showed comparable short-term results. Although both procedures were considered safe and effective in the selected group, RAT-AVR had a lower incidence of complete atrioventricular block and paravalvular regurgitation.

Limited versus full sternotomy for aortic valve replacement

BACKGROUND

Aortic valve disease is a common condition easily treatable with cardiac surgery. This is conventionally performed by opening the sternum ('median sternotomy') and replacing the valve under cardiopulmonary bypass. Median sternotomy is well tolerated, but as less invasive options become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access have raised safety concerns with regard to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity. This is an update of a Cochrane review first published in 2017, with seven new studies.

OBJECTIVES

To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement.

SEARCH METHODS

We performed searches of CENTRAL, MEDLINE and Embase from inception to August 2021, with no language limitations. We also searched two clinical trials registries and manufacturers' websites. We reviewed references of primary studies to identify any further studies of relevance.

SELECTION CRITERIA

We included randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, transapical, transfemoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. We determined the certainty of evidence using the GRADE methodology and summarised results of patient-relevant outcomes in a summary of findings table.

MAIN RESULTS

The review included 14 trials with 1395 participants. Most studies had at least two domains at high risk of bias. We analysed 14 outcomes investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy. Upper hemi-sternotomy may have little to no effect on mortality versus full median sternotomy (risk ratio (RR) 0.93, 95% confidence interval (CI) 0.45 to 1.94; 10 studies, 985 participants; low-certainty evidence). Upper hemi-sternotomy for aortic valve replacement may increase cardiopulmonary bypass time slightly, although the evidence is very uncertain (mean difference (MD) 10.63 minutes, 95% CI 3.39 to 17.88; 10 studies, 1043 participants; very low-certainty evidence) and may increase aortic cross-clamp time slightly (MD 6.07 minutes, 95% CI 0.79 to 11.35; 12 studies, 1235 participants; very low-certainty evidence), although the evidence is very uncertain. Most studies had at least two domains at high risk of bias. Postoperative blood loss was probably lower in the upper hemi-sternotomy group (MD -153 mL, 95% CI -246 to -60; 8 studies, 767 participants; moderate-certainty evidence). Low-certainty evidence suggested that there may be no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.19, 95% CI -0.43 to 0.04; 5 studies, 649 participants). Upper hemi-sternotomy may result in little to no difference in quality of life (MD 0.03 higher, 95% CI 0 to 0.06 higher; 4 studies, 624 participants; low-certainty evidence). Two studies reporting index admission costs concluded that limited sternotomy may be more costly at index admission in the UK National Health Service (MD 1190 GBP more, 95% CI 420 GBP to 1970 GBP, 2 studies, 492 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

The evidence was of very low to moderate certainty. Sample sizes were small and underpowered to demonstrate differences in some outcomes. Clinical heterogeneity was also noted. Considering these limitations, there may be little to no effect on mortality. Differences in extracorporeal support times are uncertain, comparing upper hemi-sternotomy to full sternotomy for aortic valve replacement. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from also performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality of life analyses to be included as end points, as well as quantitative measures of physiological reserve.

Recent improvement in operative techniques lead to lower pacemaker rate after Perceval implant

Central picture.

Morphologic investigation on Perceval S, a sutureless pericardial valve prosthesis: collagen integrity after collapsing-ballooning and structural valve deterioration at distance

Perceval S is a self-expandable, stent-mounted bioprosthetic valve (BPV), with glutaraldehyde treated bovine pericardium, processed with homocysteic acid as an anti-calcification treatment. The stent is crimpable but the valve insertion is done surgically via a shorter procedure which does not require sutures. OBJECTIVES: MATERIAL AND METHODS: RESULTS: CONCLUSIONS: Collapsing and ballooning do not alter cusp collagen periodicity. Structural valve deterioration with stenosis, due to dystrophic calcification and fibrous tissue overgrowth, seldom occurred in the mid-term. Glutaraldehyde fixed pericardium has the potential to undergo structural valve deterioration with time, similar to well-known BPV failure. This supports the recommendation to pursue improvement of tissue valve treatment with enhanced durability.

Clinical outcomes after implantation of a sutureless aortic bioprosthesis with concomitant mitral valve surgery: the SURE-AVR registry

Background

Early treatment of aortic valve stenosis is recommended in eligible symptomatic patients with severe aortic valve stenosis who would otherwise have a poor prognosis. The sutureless aortic valve bioprosthesis offers an alternative to standard aortic valve replacement with a sutured valve, but limited data are available in patients who have undergone multiple valve procedures involving the new, sutureless technology. We sought to investigate outcomes in high operative risk patients with previous or concomitant valve surgery who were implanted with a sutureless valve.

Methods

SURE-AVR is an ongoing, prospective, multinational registry of patients undergoing aortic valve replacement. In-hospital and post-discharge outcomes up to 5 years were collected.

Results

The study population comprised 78 patients (mean ± SD: age 73.6 ± 7.6 years, logistic EuroSCORE 18.0 ± 17.5) enrolled at 13 sites who presented for concomitant or previous mitral valve repair (n = 45) or replacement (n = 33), with or without additional concomitant procedures, and were implanted with a sutureless valve. Mean ± SD overall aortic cross-clamp time was 109 ± 41 min and cardiopulmonary bypass time was 152 ± 49 min. Mean ± SD aortic pressure gradients decreased from 37.6 ± 17.7 mmHg preoperatively to 13.0 ± 5.7 mmHg at hospital discharge, and peak aortic pressure gradient from 61.5 ± 28.7 to 23.4 ± 10.6 mmHg. Early events included 1 death, 1 transient ischaemic attack, and 1 bleed (all 1.3%); a permanent pacemaker implantation was required in 6 patients (7.7%), and 2 reoperations (not valve related) (2.6%) took place. Over a median follow-up of 55.5 months (Q1 13.4, Q3 68.6), 12 patients died (6 cardiovascular and 6 non-cardiovascular, both 2.1% per patient-year). Five-year survival was 81.3%. Late paravalvular leak occurred in 2 patients (0.7% per patient-year) and permanent pacemaker implantation was required in 3 patients (0.1% per patient-year). There was no apparent rise in mean or peak aortic pressure gradient over the study.

Conclusions

These results suggest that the sutureless implant is a technically feasible procedure during mitral surgery and is associated with good clinical outcomes.

Balloon aortic valvuloplasty: Treatment of rapid deployment aortic valve replacement complicated by a paravalvular leak

The Edwards Intuity Elite valve system was designed to facilitate minimally invasive surgery and streamline complex aortic valve replacements and has since gained more popularity. Despite the superior results shown with rapid deployment aortic valve replacement (RDAVR) utilizing this valve system, paravalvular leaks (PVL), as a complication, remains a concern. Currently, there is no universally agreed single treatment option. A 53-year-old male with a history of well-controlled diabetes mellitus and hypertension presented to the emergency room with a 1-month history of angina, syncope on exertion and dyspnea. On further workup, he was found to have severe aortic stenosis in the setting of a bicuspid aortic valve, with non-obstructive coronary artery disease. He proceeded to urgent RDAVR with a 23 mm Edwards Intuity Valve. Six months post-RDAVR he re-presented with dyspnea on exertion and near syncopal episodes. Postoperative transthoracic and transesophageal echocardiography revealed moderate to severe PVL posterior to the prosthetic aortic valve. Balloon valvuloplasty with a 25 mm True Balloon was performed. Resolution of the PVL was confirmed postprocedure both by angiography and echocardiography. The patient was followed for 1 year and remained symptom-free with evidence of mild PVL on surveillance echocardiography. In conclusion, multiple treatment options for RDAVR complicated by PVL exist; however mid to long-term outcome data are lacking. We presented one such case successfully treated with balloon aortic valvuloplasty.

Aortic Valve Replacement with a Conventional Stented Bioprosthesis versus Sutureless Bioprosthesis: a Study of 763 Patients

OBJECTIVE

The aim of this retrospective study was to compare early postoperative outcomes after aortic valve replacement (AVR) with sutureless bioprostheses and conventional stented bioprostheses implanted through median sternotomy.

METHODS

From January 2011 to December 2016, 763 patients underwent aortic valve replacement with bioprostheses; of these, 139 received a Perceval S sutureless valve (Group A) and 624 received a Perimount Magna Ease valve (Group B). These groups were further divided into A1 (isolated Perceval AVR), A2 (Perceval AVR with coronary artery bypass grafting [CABG]), B1 (isolated conventional stented bioprosthesis), and B2 (conventional stented bioprosthesis + CABG).

RESULTS

Patients in Group A were older (mean 74 years vs. 71 years; P<0.0001), predominantly women (53% vs. 32%; P<0.0001), had a higher logistic EuroSCORE (3.26 vs. 2.43; P<0.001), more preoperative atrial fibrillation (20% vs. 13%; P=0.03), and had a lower reopening rate for bleeding (2.1% vs. 6.7%; P=0.04). Compared to Group B1, Group A1 had shorter cross-clamp (mean 40 min vs. 57 min; P≤0.0001) and bypass times (mean 63 min vs. mean 80 min; P=0.02), and they bled less postoperatively (mean 295 ml vs. mean 393 ml; P=0.002). The mean gradient across Perceval valve was 12.5 mmHg while its effective orifice area was 1.5 cm2.

CONCLUSION

In our retrospective study of 763 patients, sutureless valve group patients are older, mostly women, more symptomatic preoperatively, and have higher logistic EuroSCORE. They have shorter cross-clamp and bypass times, less postoperative bleeding, and reduced incidence of reopening. Further studies are needed to evaluate the clinical benefits in short, mid, and long-terms.

Early Clinical Results of Perceval Sutureless Aortic Valve in 139 Patients: Freeman Experience

Objective

The aim of this retrospective study is to evaluate the safety and performance of the Perceval sutureless valve in patients undergoing aortic valve replacement. We report the 30-day clinical outcomes of 139 patients.

Methods

From January 2014 to December 2016, 139 patients underwent sutureless aortic valve replacement. Their operation notes, National Adult Cardiac Surgery Database and perioperative transoesophageal echocardiography findings were studied retrospectively.

Results

Ninety-two patients underwent isolated aortic valve replacement (group A) with Perceval valve and 47 patients had combined procedures of aortic valve replacement and coronary artery bypass grafting (group B). The patients received a size S (n=23), M (n=39), L (n=42) or XL (n=35) prosthesis. Perceval valve was successfully implanted in 135 (97.1%) patients. Mean cross-clamping time and bypass time were 40 and 63 minutes for isolated cases, while 68 and 107 minutes for combined cases. Three (2.1%) patients died within 30 days. Four patients suffered stroke and 5 patients went into acute renal failure. Median intensive care unit and hospital stay was 2 and 8.5, respectively. Four valves were explanted due to significant paravalvular leak after surgery. Five patients had permanent pacemaker as a result of complete heart block and mean postoperative drainage was 295 mL for isolated case and 457 mL for combined cases. The mean gradient across Perceval valve was 12.5 mmHg while its effective orifice area was 1.5 cm².

Conclusion

Early postoperative results showed that Perceval valve is safe. Further follow up is needed to evaluate the long-term outcome with this bioprosthesis.

Sutureless versus Conventional Aortic Valve Replacement: Outcomes in 70 High-Risk Patients Undergoing Concomitant Cardiac Procedures

In elderly, high-risk surgical patients, sutureless aortic valve replacement (AVR) can often be an alternative to conventional AVR; shorter aortic cross-clamp and cardiopulmonary bypass times are the chief advantages. We compared the outcomes of sutureless AVR with those of conventional AVR in 70 elderly patients who underwent concomitant cardiac surgical procedures. We retrospectively analyzed the cases of 42 men and 28 women (mean age, 70.4 ± 10.3 yr; range, 34-93 yr) who underwent cardiac operations plus AVR with either a sutureless valve (group 1, n=38) or a conventional bioprosthetic or mechanical valve (group 2, n=32). Baseline patient characteristics were similar except for worse New York Heart Association functional status and the prevalence of diabetes mellitus in group 1. In group 1, the operative, cross-clamp, and cardiopulmonary bypass times were shorter (all P=0.001), postoperative drainage amounts were lower (P=0.009), hospital stays were shorter (P=0.004), and less red blood cell transfusion was needed (P=0.037). Echocardiograms before patients' discharge from the hospital showed lower peak and mean aortic gradients in group 1 (mean transvalvular gradient, 8.4 ± 2.8 vs 12.2 ± 5.2 mmHg; P=0.012). We found that elderly, high-risk patients who underwent multiple cardiac surgical procedures and sutureless AVR had better hemodynamic outcomes and shorter ischemic times than did patients who underwent conventional AVR.

The Use of Rapid Deployment Valves in Combined Aortic and Mitral Valve Surgery: One-Year Clinical and Echocardiographic Outcomes

OBJECTIVE

Patients undergoing multiple valve surgery represent a high-risk group who could potentially benefit from a reduction of cross-clamp and cardiopulmonary bypass times because prolonged bypass and cross-clamp times are considered independent risk factors for increased morbidity and mortality after cardiac surgery.

METHODS

Between July 2013 and November 2014, 16 patients underwent rapid deployment aortic valve replacement with the EDWARDS INTUITY valve system in the setting of concomitant mitral disease. Fifteen patients showed mitral regurgitation, whereas one patient had severe mitral stenosis. Fourteen patients received mitral valve repair and two patients received biological mitral valve replacement. Tricuspid valve repair was performed additionally in two patients. The mean ± SD age was 72.8 ± 8.4 years, and the mean ± SD logistic EuroSCORE II is 8.7% ± 3.4%.

RESULTS

Within a 30-day perioperative period, no patient was lost (n = 0). The mean ± SD follow-up time was 11 ± 2 months. At 1 year, the overall survival was 81% (n = 13). A mean ± SD transaortic gradient of 10.7 ± 2.3 mm Hg and a mean ± SD effective orifice area of 1.7 ± 0.3 cm were measured echocardiographically. No higher-grade paravalvular leak (aortic insufficiency > 1+) occurred. Eight patients (61%) had no residual mitral regurgitation, four patients (30%) showed trivial regurgitation (1/4), and one patient (7.3%) had moderate mitral regurgitation (2/4). No interference of the subannular stent frame with the reconstructed valve or the biological mitral prosthesis was seen.

CONCLUSIONS

Rapid deployment aortic valve replacement with the EDWARDS INTUITY valve system in combined aortic and mitral valve surgery can be performed safely with reproducible results. One-year follow-up data of this small series shows encouraging results potentially justifying the extension of the indication for rapid deployment valves to patients with concomitant mitral disease. Especially elderly patients undergoing multiple valve surgery may benefit from a reduction of cardiopulmonary bypass and myocardial ischemic times.

Limited versus full sternotomy for aortic valve replacement

BACKGROUND

Aortic valve disease is a common condition that is easily treatable with cardiac surgery. This is conventionally performed by opening the sternum longitudinally down the centre ("median sternotomy") and replacing the valve under cardiopulmonary bypass. Median sternotomy is generally well tolerated, but as less invasive options have become available, the efficacy of limited incisions has been called into question. In particular, the effects of reducing the visibility and surgical access has raised safety concerns with regards to the placement of cannulae, venting of the heart, epicardial wire placement, and de-airing of the heart at the end of the procedure. These difficulties may increase operating times, affecting outcome. The benefits of smaller incisions are thought to include decreased pain; improved respiratory mechanics; reductions in wound infections, bleeding, and need for transfusion; shorter intensive care stay; better cosmesis; and a quicker return to normal activity.

OBJECTIVES

To assess the effects of minimally invasive aortic valve replacement via a limited sternotomy versus conventional aortic valve replacement via median sternotomy in people with aortic valve disease requiring surgical replacement.

SEARCH METHODS

We performed searches of CENTRAL, MEDLINE, Embase, clinical trials registries, and manufacturers' websites from inception to July 2016, with no language limitations. We reviewed references of identified papers to identify any further studies of relevance.

SELECTION CRITERIA

Randomised controlled trials comparing aortic valve replacement via a median sternotomy versus aortic valve replacement via a limited sternotomy. We excluded trials that performed other minimally invasive incisions such as mini-thoracotomies, port access, trans-apical, trans-femoral or robotic procedures. Although some well-conducted prospective and retrospective case-control and cohort studies exist, these were not included in this review.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed trial papers to extract data, assess quality, and identify risk of bias. A third review author provided arbitration where required. The quality of evidence was determined using the GRADE methodology and results of patient-relevant outcomes were summarised in a 'Summary of findings' table.

MAIN RESULTS

The review included seven trials with 511 participants. These included adults from centres in Austria, Spain, Italy, Germany, France, and Egypt. We performed 12 comparisons investigating the effects of minimally invasive limited upper hemi-sternotomy on aortic valve replacement as compared to surgery performed via full median sternotomy.There was no evidence of any effect of upper hemi-sternotomy on mortality versus full median sternotomy (risk ratio (RR) 1.01, 95% confidence interval (CI) 0.36 to 2.82; participants = 511; studies = 7; moderate quality). There was no evidence of an increase in cardiopulmonary bypass time with aortic valve replacement performed via an upper hemi-sternotomy (mean difference (MD) 3.02 minutes, 95% CI -4.10 to 10.14; participants = 311; studies = 5; low quality). There was no evidence of an increase in aortic cross-clamp time (MD 0.95 minutes, 95% CI -3.45 to 5.35; participants = 391; studies = 6; low quality). None of the included studies reported major adverse cardiac and cerebrovascular events as a composite end point.There was no evidence of an effect on length of hospital stay through limited hemi-sternotomy (MD -1.31 days, 95% CI -2.63 to 0.01; participants = 297; studies = 5; I2 = 89%; very low quality). Postoperative blood loss was lower in the upper hemi-sternotomy group (MD -158.00 mL, 95% CI -303.24 to -12.76; participants = 297; studies = 5; moderate quality). The evidence did not support a reduction in deep sternal wound infections (RR 0.71, 95% CI 0.22 to 2.30; participants = 511; studies = 7; moderate quality) or re-exploration (RR 1.01, 95% CI 0.48 to 2.13; participants = 511; studies = 7; moderate quality). There was no change in pain scores by upper hemi-sternotomy (standardised mean difference (SMD) -0.33, 95% CI -0.85 to 0.20; participants = 197; studies = 3; I2 = 70%; very low quality), but there was a small increase in postoperative pulmonary function tests with minimally invasive limited sternotomy (MD 1.98 % predicted FEV1, 95% CI 0.62 to 3.33; participants = 257; studies = 4; I2 = 28%; low quality). There was a small reduction in length of intensive care unit stays as a result of the minimally invasive upper hemi-sternotomy (MD -0.57 days, 95% CI -0.93 to -0.20; participants = 297; studies = 5; low quality). Postoperative atrial fibrillation was not reduced with minimally invasive aortic valve replacement through limited compared to full sternotomy (RR 0.60, 95% CI 0.07 to 4.89; participants = 240; studies = 3; moderate quality), neither were postoperative ventilation times (MD -1.12 hours, 95% CI -3.43 to 1.19; participants = 297; studies = 5; low quality). None of the included studies reported cost analyses.

AUTHORS' CONCLUSIONS

The evidence in this review was assessed as generally low to moderate quality. The study sample sizes were small and underpowered to demonstrate differences in outcomes with low event rates. Clinical heterogeneity both between and within studies is a relatively fixed feature of surgical trials, and this also contributed to the need for caution in interpreting results.Considering these limitations, there was uncertainty of the effect on mortality or extracorporeal support times with upper hemi-sternotomy for aortic valve replacement compared to full median sternotomy. The evidence to support a reduction in total hospital length of stay or intensive care stay was low in quality. There was also uncertainty of any difference in the rates of other, secondary outcome measures or adverse events with minimally invasive limited sternotomy approaches to aortic valve replacement.There appears to be uncertainty between minimally invasive aortic valve replacement via upper hemi-sternotomy and conventional aortic valve replacement via a full median sternotomy. Before widespread adoption of the minimally invasive approach can be recommended, there is a need for a well-designed and adequately powered prospective randomised controlled trial. Such a study would benefit from performing a robust cost analysis. Growing patient preference for minimally invasive techniques merits thorough quality-of-life analyses to be included as end points, as well as quantitative measures of physiological reserve.

Minimally Invasive Versus Conventional Aortic Valve Replacement: A Propensity-Matched Study From the UK National Data

Minimally invasive aortic valve replacement (MIAVR) has been demonstrated as a safe and effective option but remains underused. We aimed to evaluate outcomes of isolated MIAVR compared with conventional aortic valve replacement (CAVR).

Transcatheter aortic valve implantation (TAVI) versus sutureless aortic valve replacement (SUAVR) for aortic stenosis: a systematic review and meta-analysis of matched studies

BACKGROUND

With improving technologies and an increasingly elderly populations, there have been an increasing number of therapeutic options available for patients requiring aortic valve replacement. Recent evidence suggests that transcatheter aortic valve implantation (TAVI) is one suitable option for high risk inoperable patients, as well as high risk operable patients. Sutureless valve technology has also been developed concurrently, with facilitates surgical aortic valve replacement (SUAVR) by allow resection and replacement of the native aortic valve with minimal sutures and prosthesis anchoring required. For patients amenable for both TAVI and SUAVR, the evidence is unclear with regards to the benefits and risks of either approach. The objectives are to compare the perioperative outcomes and intermediate-term survival rates of TAVI and SUAVR in matched or propensity score matched studies.

METHODS

A systematic literature search was performed to include all matched or propensity score matched studies comparing SUAVR versus TAVI for severe aortic stenosis. A meta-analysis with odds ratios (OR) and mean differences were performed to compare key outcomes including paravalvular regurgitation and short and intermediate term mortality.

RESULTS

Six studies met our inclusion criteria giving a total of 741 patients in both the SUAVR and TAVI arm of the study. Compared to TAVI, SUAVR had a lower incidence of paravalvular leak (OR =0.06; 95% CI: 0.03-0.12, P<0.01). There was no difference in perioperative mortality, however SUAVR patients had significantly better survival rates at 1 (OR =2.40; 95% CI: 1.40-4.11, P<0.01) and 2 years (OR =4.62; 95% CI: 2.62-8.12, P<0.01).

CONCLUSIONS

The present study supports the use of minimally invasive SUAVR as an alternative to TAVI in high risk patients requiring aortic replacement. The presented results require further validation in prospective, randomized controlled studies.

Transcatheter aortic valve implantation in degenerative sutureless perceval aortic bioprosthesis

Sutureless aortic bioprostheses (SAB) are increasingly being used to provide shorter cross-clamp time. Valve-in-valve transcatheter aortic valve replacement (VIV-A) is shown to be effective and safe in the vast majority of patients with degenerated bioprosthetics, yet its' use in SAB failure is infrequent. We present a case of balloon-expandable VIV-A in an 80-year-old woman who suffered severe symptomatic aortic regurgitation in a failed Perceval S 21-mm valve. Computed tomography scan demonstrated a deformed valve. Our heart team favored a percutaneous VIV-A over reoperation due to the patients' high surgical risk. An Edwards-Sapien XT 23 mm was successfully deployed with excellent results. The patient remained asymptomatic following 6 months. As other bioprosthesis, some sutureless valves are condemned to structural valve degeneration. Because VIV-A is being established for managing degenerative bioprosthesis in high risk patients, it is cardinal to identify its role in novel degenerative sutureless valves. SAB were introduced to the clinical market only 5-7 years ago. The absence of sutures may theoretically impose risk for valve instability when adding a transcatheter sutureless valve inside the first one. Our successful experience was very reassuring. We report its feasibility because we believe it should provide support for further investigation on VIV-A within novel SAV. © 2016 Wiley Periodicals, Inc.

Comparison of the Performance of a Sutureless Bioprosthesis With Two Pericardial Stented Valves on Small Annuli: An In Vitro Study

BACKGROUND

Aortic valve replacement has evolved recently with the development of the sutureless bioprosthesis. One such valve is the Perceval bioprosthesis, which is built by mounting leaflets of bovine pericardium to a thin stent; this approach has the potential to provide an excellent fluid dynamic performance. We undertook an in vitro study to compare the hydrodynamic performance of the sutureless bioprosthesis with two standard pericardial stented bioprostheses (Crown and Magna).

METHODS

Tests were conducted using a mock loop, testing on two sizes of the three prostheses. The prosthesis sizes were chosen to house the valves in porcine aortic roots with a native annulus diameter of 19 mm (n = 6) or 21 mm (n = 6). The stroke volume ranged from 25 mL to 105 mL at a simulated heart rate of 70 beats per minute.

RESULTS

Mean pressure drop and energy loss rose with increasing stroke volume in all of the valves tested (p < 0.001), with the sutureless valve showing the lowest values for both variables (p < 0.001). Effective orifice area values were stable across the stroke volume intervals and were larger in the sutureless valves (p < 0.001).

CONCLUSIONS

All of the valves tested provided good fluid dynamic performances. The sutureless bioprosthesis provided the best performance with the least hindrance to flow behavior. From the hydrodynamic perspective, the sutureless prosthesis may present an advance in the evolution of bioprostheses, ensuring low gradients and potential for low incidence of patient-prosthesis mismatch even in small annuli.

[Aortic valve replacement in the elderly]

The treatment of severe symptomatic aortic valve stenosis by conventional aortic valve replacement (AVR) or by transcatheter aortic valve implantation (TAVI) has a good perinterventional prognosis even for patients of advanced age. Having a heart team select the best management strategies based on current guidelines for each individual patient is essential for success. Especially in elderly and increasingly multimorbid patients with sometimes severe preconditions, the detection of functional deficits is relevant not only for the mortality but also for perioperative and postoperative complications as well as the functional outcome. Various methods of geriatric assessment are important supplements to standard risk scores. The aim is to implement targeted interventions to minimize the risk factors and to improve the prognosis for elderly patients. The aim of this article is to provide an overview of the current therapy options for aortic valve replacement and to summarize current aspects of treatment options for elderly patients.

Early Outcomes of Sutureless Aortic Valves

Background

In elderly high-risk surgical patients, sutureless aortic valve replacement (AVR) should be an alternative to standard AVR. The potential advantages of sutureless aortic prostheses include reducing cross-clamping and cardiopulmonary bypass (CPB) time and facilitating minimally invasive surgery and complex cardiac interventions, while maintaining satisfactory hemodynamic outcomes and low rates of paravalvular leakage. The current study reports our single-center experience regarding the early outcomes of sutureless aortic valve implantation.

Methods

Between October 2012 and June 2015, 65 patients scheduled for surgical valve replacement with symptomatic aortic valve disease and New York Heart Association function of class II or higher were included to this study. Perceval S (Sorin Biomedica Cardio Srl, Sallugia, Italy) and Edwards Intuity (Edwards Lifesciences, Irvine, CA, USA) valves were used.

Results

The mean age of the patients was 71.15±8.60 years. Forty-four patients (67.7%) were female. The average preoperative left ventricular ejection fraction was 56.9±9.93. The CPB time was 96.51±41.27 minutes and the cross-clamping time was 60.85±27.08 minutes. The intubation time was 8.95±4.19 hours, and the intensive care unit and hospital stays were 2.89±1.42 days and 7.86±1.42 days, respectively. The mean quantity of drainage from chest tubes was 407.69±149.28 mL. The hospital mortality rate was 3.1%. A total of five patients (7.69%) died during follow-up. The mean follow-up time was 687.24±24.76 days. The one-year survival rate was over 90%.

Conclusion

In the last few years, several models of valvular sutureless bioprostheses have been developed. The present study evaluating the single-center early outcomes of sutureless aortic valve implantation presents the results of an innovative surgical technique, finding that it resulted in appropriate hemodynamic conditions with acceptable ischemic time.

Exploring the learning curve for minimally invasive sutureless aortic valve replacement

OBJECTIVE

The study objective was to assess the learning process and quality of care of right minithoracotomy aortic valve replacement with a sutureless bioprosthesis at a single institution.

METHODS

We performed an analysis of the first 300 consecutive patients (aged 76 ± 6 years; logistic European System for Cardiac Operative Risk Evaluation 9 ± 6) who underwent sutureless valve implantation via a right minithoracotomy by 6 surgeons at the G. Pasquinucci Heart Hospital between 2011 and 2015. The learning curve was analyzed by dividing the study population into tertiles of 100 patients each. Departmental and individual learning curves were calculated using sequential probability cumulative sum failure analysis. Quality indicators were 2 composite end points reflecting the technical success and 30-day complications.

RESULTS

The overall mortality was 0.7% (2 patients). No significant differences were noted in terms of mortality and complications between tertiles. The sutureless valve was implanted successfully in 99% of patients (298/300). Cumulative sum analysis failed to identify any significant learning effects for technical success. Nevertheless, surgeons A, B, and C had a small initial learning curve, and surgeons D, E, and F did not, reflecting a trend toward a positive effect of cumulative institutional experience on the individual learning curve. The 30-day complications analysis revealed a cluster of failures at the beginning of the experience. This cluster prompted an internal audit and modification of the patients' selection process. Consecutively, the procedure returned in control.

CONCLUSIONS

Right minithoracotomy sutureless valve implantation can be performed safely without learning curve effects. Cumulative sum analysis is a valuable tool to describe and monitor the learning process. The analysis can identify periods of less than expected performance and alert the team to react.

The sutureless aortic valve at 1 year: A large multicenter cohort study

OBJECTIVE

Sutureless aortic valve replacement (AVR) offers an alternative to standard AVR in aortic stenosis. This prospective, single-arm study aimed to demonstrate safety and effectiveness of a bovine pericardial sutureless aortic valve at 1 year.

METHODS

From February 2010 to September 2013, 658 patients (mean age 78.3 ± 5.6 years; 40.0% octogenarian; 64.4% female; mean Society of Thoracic Surgeons score 7.2 ± 7.4) underwent sutureless AVR in 25 European centers. Concomitant cardiac procedures were performed in 29.5% and minimally invasive cardiac surgery in 33.3%.

RESULTS

One-year site-reported event rates were 8.1% for all-cause mortality, 4.5% for cardiac mortality, 3.0% for stroke, 1.9% for valve-related reoperation, 1.4% for endocarditis, and 0.6% for major paravalvular leak. No valve thrombosis, migration, or structural valve deterioration occurred. New York Heart Association class improved at least 1 level in 77.5% and remained stable (70.4% New York Heart Association class I or II at 1 year). Mean effective orifice area was 1.5 ± 0.4 cm(2); pressure gradient was 9.2 ± 5.0 mm Hg. Left ventricular mass decreased from 138.5 g/m(2) before surgery to 115.3 g/m(2) at 1 year (P < .001). Echocardiographic core laboratory findings confirmed that paravalvular leak was rare and remained stable during follow-up.

CONCLUSIONS

The Perceval sutureless valve resulted in low 1-year event rates in intermediate-risk patients undergoing AVR. New York Heart Association class improved in more than three-quarters of patients and remained stable. These data support the safety and efficacy to 1 year of the Perceval sutureless valve in this intermediate-risk population.

Minimal invasive implantation of an EDWARDS INTUITY rapid deployment aortic valve

The development of rapid deployment and sutureless aortic valves represents a translation of knowledge gained from the performance of transcutaneous aortic valve replacement (AVR) procedures combined with decades of experience of conventional AVR surgery. Such devices have gained increasing clinical acceptance-particularly in Europe-with almost 3000 total implants to date. Rapid deployment and sutureless valves facilitate minimal invasive AVR and are associated with significantly reduced myocardial ischaemic and cardiopulmonary bypass times. The reduced ischaemic times may also be important for patients requiring complex combined procedures, or those with poor left ventricular function. These devices are associated with excellent haemodynamic performance and acceptable rates of pacemaker implantation and paravalvular leak. The current case involves a minimal invasive implantation of an EDWARDS INTUITY rapid deployment valve (Edwards Lifesciences, Irvine, CA, USA).

Clinical and haemodynamic outcomes in 658 patients receiving the Perceval sutureless aortic valve: early results from a prospective European multicentre study (the Cavalier Trial)†

OBJECTIVES

The aim of the Cavalier trial was to evaluate the safety and performance of the Perceval sutureless aortic valve in patients undergoing aortic valve replacement (AVR). We report the 30-day clinical and haemodynamic outcomes from the largest study cohort with a sutureless valve.

METHODS

From February 2010 to September 2013, 658 consecutive patients (mean age 77.8 years; 64.4% females; mean logistic EuroSCORE 10.2%) underwent AVR in 25 European Centres. Isolated AVRs were performed in 451 (68.5%) patients with a less invasive approach in 219 (33.3%) cases. Of the total, 40.0% were octogenarians. Congenital bicuspid aortic valve was considered an exclusion criterion.

RESULTS

Implantation was successful in 628 patients (95.4%). In isolated AVR through sternotomy, the mean cross-clamp time and the cardiopulmonary bypass (CPB) time were 32.6 and 53.7 min, and with the less invasive approach 38.8 and 64.5 min, respectively. The 30-day overall and valve-related mortality rates were 3.7 and 0.5%, respectively. Valve explants, stroke and endocarditis occurred in 0.6, 2.1 and in 0.1% of cases, respectively. Preoperative mean and peak pressure gradients decreased from 44.8 and 73.24 mmHg to 10.24 and 19.27 mmHg at discharge, respectively. The mean effective orifice area improved from 0.72 to 1.46 cm(2).

CONCLUSIONS

The current 30-day results show that the Perceval valve is safe (favourable haemodynamic effect and low complication rate), and can be implanted with a fast and reproducible technique after a short learning period. Short cross-clamp and CPB times were achieved in both isolated and combined procedures. The Perceval valve represents a promising alternative to biological AVR, especially with a less invasive approach and in older patients.

Left ventricular mass regression after two alternative sutureless aortic bioprostheses

OBJECTIVE

Left ventricular (LV) hypertrophy in aortic stenosis (AS) constitutes a risk factor for cardiac morbidity and mortality. The aim of this study was to investigate the degree of LV mass regression after aortic valve replacement (AVR) with two alternative sutureless self-expanding strategies: Perceval S (Sorin Group, Saluggia, Italy) (P) and 3f Enable (Medtronic, ATS Medical, Minneapolis, MN USA) (E) aortic bioprostheses.

METHODS

Between March 2010 and December 2011, 129 patients with symptomatic AS underwent AVR with the Perceval S or 3f Enable bioprostheses in two cardiac surgery departments (Massa, Italy; Nuremberg, Germany). We analyzed 45 patients in group P and 19 in group E undergoing isolated AVR with a 6-month follow-up. The LV mass was calculated using the Devereux formula and was indexed to body surface area.

RESULTS

Baseline patient characteristics showed no significant differences between the two groups. There were no in-hospital deaths. Two patients in group P died at follow-up versus zero in group E (P = 0.49). Mean LV mass index decreased from 146.6 (78) g/m at baseline to 123.3 (63) g/m at follow-up (P < 0.001) in group P and from 146.1 (47.6) g/m to 118.1 (39.8) g/m (P = 0.003) in group E, with no significant difference between the two groups (P = 0.315). This effect was accompanied by significant clinical improvement.

CONCLUSIONS

In isolated AS, AVR with sutureless bioprostheses is associated with a significant regression in LV mass at 6-month follow-up. No significant differences were present between the two alternative sutureless strategies. However, regression needs an evaluation with long-term echocardiographic examinations.

Sutureless aortic valve replacement for aortic incompetence

OBJECTIVE

Sutureless prostheses for surgical aortic valve replacement (AVR) are usually used in degenerative calcified aortic stenosis. Less is known on the application of sutureless prostheses for pure aortic incompetence.

METHODS

Between 2011 and 2014, 442 patients were operated on with the Perceval aortic sutureless valve implant. We identified 11 patients (10 female, mean age 70.5) who underwent sutureless AVR for pure aortic incompetence (off-label use). Three patients had a left ventricle ejection fraction of 30% or less. Mean logistic EuroSCORE was 15.2 (range 2.2-45.2). In five patients associated mitral procedures (three [60%] repair and two [40%] replacement) were performed. Four procedures were performed through a minimally invasive approach (three right minithoracotomies and one partial sternotomy).

RESULTS

Mean cardiopulmonary bypass time was 130.2 min and aortic cross clamp time was 82.2 min. Mean implanted prosthesis size was 24.5 ± 1.3 (median 25) mm (insignificant correlation with preoperative aortic valve annulus measurement by transthoracic echocardiography: 21.6 ± 1.5 [median 21] mm, Pearson's r = 0.373, p = 0.259). One patient died on 24th day after AVR associated with aortic arch replacement and hypothermic circulatory arrest (10 years after correction for type A aortic dissection). No residual para- or intravalvular leakage was present on discharge and 12-month follow-up. No migration of the prosthesis occurred.

CONCLUSION

Sutureless AVR is an option in selected patients with aortic incompetence. Preoperative aortic annulus measurement by echocardiography has poor predictive value for estimation of prosthetic valve size.

Current status of surgical treatment for aortic valve stenosis

In this review, we discuss the current surgical treatment for aortic valve stenosis. Surgical strategy for treatment of aortic valve stenosis is based on the risk profile of the patient. We reviewed the existing literature and present the current state of the art of these various approaches, taking into account clinical outcomes, quality of life, costs, and learning curve.

Two alternative sutureless strategies for aortic valve replacement: a two-center experience

OBJECTIVE

Important comorbid conditions in patients referred for aortic valve replacement (AVR) require less invasive strategies. We describe our initial experience with the Perceval S (Sorin Group, Saluggia, Italy) and 3f Enable (Medtronic, Minneapolis, MN USA) sutureless aortic bioprostheses.

METHODS

We compared intraoperative data, postoperative clinical outcomes, and echocardiographic results from patients receiving a Perceval S (P group; n = 97) or a 3f Enable (E group; n = 32) prosthesis in two cardiac surgery departments (Nuremberg, Germany, and Massa, Italy).

RESULTS

Baseline patient characteristics were similar in both groups, except for mean ± SD body surface area (P group = 2.01 ± 2.9 m, E group = 1.83 ± 3.8 m; P < 0.001). Sixty-five patients (67%) in the P group and 19 patients (59.5%) in the E group (P = 0.22) underwent minimally invasive AVR with either ministernotomy or right anterior minithoracotomy approach. Concomitant procedures were performed in 37 patients (38%) in the P group and 9 patients (28%) in the E group (P = 0.56). In-hospital mortality was 2%. The mean ± SD prosthesis diameter was 23.5 ± 1.4 mm (P group) compared with 22.1 ± 2 mm (E group) (P < 0.001). In isolated AVR, aortic cross-clamp time was 36 ± 12.7 minutes in the P group and 66 ± 18 minutes in the E group (P < 0.001). At a mean ± SD follow-up of 8.3 ± 4.5 months, survival was 97% (one death in the P group). In five patients (P group = 1, E group = 4), a moderate paravalvular leak was present (P = 0.013). The mean ± SD transvalvular gradient was 9.1 ± 3.3 mm Hg with the Perceval S and 11.2 ± 5.2 mm Hg with the 3f Enable (P = 0.017).

CONCLUSIONS

Aortic valve replacement with sutureless aortic bioprosthesis is feasible, also with a minimally invasive approach. The Perceval S showed lower operative times and moderate paravalvular leaks and lower mean transvalvular gradients than did the 3f Enable, related to the larger diameter of the Perceval S implanted. Both prostheses showed an excellent hemodynamic performance. This new technology needs long-term follow-up.