Aortic Valve Replacement With Perceval Bioprosthesis: Single-Center Experience With 617 Implants

Sutureless aortic valves in isolated and combined procedures: Thirteen years of experience in 784 patients

OBJECTIVE

The aim of this study was to evaluate the outcome and experience of the Perceval sutureless valve at our institution (UZ Leuven).

METHODS

Between 2007 and 2019, 784 patients underwent sutureless aortic valve replacement using the Perceval valve (isolated or combined with other procedures). We performed a retrospective analysis of the postoperative and follow-up data.

RESULTS

Mean age was 78 years with a median European System for Cardiac Operative Risk Evaluation II score of 4.2% (interquartile range, 2.6%-7.2%). Isolated aortic valve replacement accounted for 45% of cases; 30% of cases were aortic valve replacement in combination with coronary artery bypass grafting and the remaining 25% were other combined procedures. The median crossclamp times were 38 minutes in single aortic valve replacement, 70 minutes in cases with coronary artery bypass grafting, and 89 minutes in multiple valve cases. Device success was 99.1% and in-hospital mortality was 3.3%. Postoperative stroke or transient ischemic attack occurred in 1.9% of patients and 1% of patients had a new need for dialysis after surgery and median survival time was 7.0 years with a cumulative follow-up of 2797.8 patient-years. The 1-, 5-, and 10-year freedom from reintervention were 99%, 97%, and 94%, respectively.

CONCLUSIONS

These data represent the longest follow-up available, to our knowledge, for the Perceval sutureless valve. We observed favorable early outcomes, and low rates of early mortality, stroke, and other major complications. Valve durability is promising with low rates of valve degeneration and a limited need for reintervention.

Semiautonomous Robotic Manipulator for Minimally Invasive Aortic Valve Replacement

Aortic valve surgery is the preferred procedure for replacing a damaged valve with an artificial one. The ValveTech robotic platform comprises a flexible articulated manipulator and surgical interface supporting the effective delivery of an artificial valve by teleoperation and endoscopic vision. This article presents our recent work on force-perceptive, safe, semiautonomous navigation of the ValveTech platform prior to valve implantation. First, we present a force observer that transfers forces from the manipulator body and tip to a haptic interface. Second, we demonstrate how hybrid forward/inverse mechanics, together with endoscopic visual servoing, lead to autonomous valve positioning. Benchtop experiments and an artificial phantom quantify the performance of the developed robot controller and navigator. Valves can be autonomously delivered with a 2.0±0.5 mm position error and a minimal misalignment of 3.4±0.9°. The hybrid force/shape observer (FSO) algorithm was able to predict distributed external forces on the articulated manipulator body with an average error of 0.09 N. FSO can also estimate loads on the tip with an average accuracy of 3.3%. The presented system can lead to better patient care, delivery outcome, and surgeon comfort during aortic valve surgery, without requiring sensorization of the robot tip, and therefore obviating miniaturization constraints.

Sutureless versus transcatheter valves in patients with aortic stenosis at intermediate risk: A multi-institutional European study

BACKGROUND

Recent randomized controlled trials showed comparable short-term outcomes of transcatheter aortic valve implantation versus surgical aortic valve replacement in intermediate and low-risk patients. However, independent studies comparing transcatheter aortic valve implantation results versus surgical aortic valve replacement at 5 years showed worsening outcomes in patients treated with transcatheter aortic valve implantation. The aim of this study was to analyze mid- to long-term outcomes of patients with isolated aortic stenosis and an intermediate-risk profile who underwent aortic valve replacement using a sutureless valve versus transcatheter aortic valve implantation.

METHODS

This retrospective multi-institutional European study investigated 2,123 consecutive patients with isolated aortic stenosis at intermediate risk profile treated with sutureless aortic valve replacement (824 patients) or transcatheter aortic valve implantation (1,299 patients) from 2013 to 2020. After 1:1 propensity score matching, 2 balanced groups of 517 patients were obtained. Primary endpoints were as follows: 30 days, late all-cause, and cardiac-related mortality. Secondary endpoints included major adverse cardiocerebrovascular events (all-cause death, stroke/transient ischemic attack, endocarditis, reoperation, permanent pacemaker implantation, and paravalvular leak grade ≥2).

RESULTS

Median follow-up was 4.3 years (interquartile range 1.1-7.4 years). Primary endpoints were as follows-30-day mortality sutureless aortic valve replacement: 2.13% versus transcatheter aortic valve implantation: 4.64% (P = .026), all-cause mortality sutureless aortic valve replacement: 36.7% ± 7.8% vs transcatheter aortic valve implantation: 41.8% ± 8.2% (P = .023), and cardiac-related mortality sutureless aortic valve replacement: 10.2% ± 2.8% vs transcatheter aortic valve implantation: 19.2% ± 3.5%;(P = .00043) at follow-up. Secondary endpoints were as follows-major adverse cardiocerebrovascular events in the sutureless aortic valve replacement group: 47.2% ± 9.0% versus transcatheter aortic valve implantation: 57.3% ± 7.5% (P < .001). In particular, the incidence of permanent pacemaker implantation (sutureless aortic valve replacement: 6.38% versus transcatheter aortic valve implantation: 11.8% [P = .002]) and paravalvular leak ≥2 (sutureless aortic valve replacement: 0.97% versus transcatheter aortic valve implantation: 4.84% [P = .001]) was significantly higher in transcatheter aortic valve implantation group. At Multivariable Cox regression analysis, paravalvular leak ≥2 (hazard ratio: 1.63%; 95% confidence interval: 1.06-2.53, P = .042) and permanent pacemaker implantation (hazard ratio: 1.49%; 95% confidence interval: 1.02-2.20, P = .039) were identified as predictors of mortality.

CONCLUSION

Sutureless aortic valve replacement showed a significantly lower incidence of all-cause mortality, cardiac-related death, permanent pacemaker implantation, and paravalvular leak than transcatheter aortic valve implantation. Moreover, permanent pacemaker implantation and paravalvular leak negatively affected survival in patients treated for isolated aortic stenosis.

Single-Center Real-World Experience with Sutureless Aortic Valve Prosthesis in Isolated and Combined Procedures

INTRODUCTION

Due to their favourable hemodynamic performance and the ability to enable minimally invasive access procedures, sutureless aortic valve prostheses have found their place in the armamentarium of cardiothoracic surgeons. In this study, we sought to review our institutional experience of sutureless aortic valve replacement (SU-AVR).

METHODS

We carried out a retrospective analysis of 200 consecutive patients who underwent an SU-AVR with a Perceval valve between December 2019 and February 2023.

RESULTS

The mean age of patients was 69.3 ± 8.1 years, and patients showed a moderate-risk profile with a mean logistic EuroSCORE-II of 5.2 ± 8.1%. An isolated SU-AVR was performed in 85 (42.5%) patients, concomitant CABG was performed in 75 (37.5%) and 40 patients (20%) underwent a multivalve procedure involving SU-AVR. The cardiopulmonary bypass (CPB) and cross-clamp (CC) times were 82.1 ± 35.1 and 55.5 ± 27.8 min, respectively. In-hospital, 30-day, 6-month and 1-year mortality rates were 4.5%, 6.5%, 7.5% and 8.2%, respectively. The postoperative transvalvular mean pressure gradient was 6.3 ± 1.6 mmHg and stayed stable over the follow-up time. We reported no cases of paravalvular leakage, and the incidence of stroke was 0.5%.

CONCLUSIONS

With their favourable hemodynamic performance and shorter CC and CPB times, sutureless aortic valve prostheses facilitate minimally invasive access surgery, being a safe and durable promising approach for the surgical AVR.

Hemodynamic Performance of Sutureless vs. Conventional Bioprostheses for Aortic Valve Replacement: The 1-Year Core-Lab Results of the Randomized PERSIST-AVR Trial

Objective

Sutureless aortic valves are an effective option for aortic valve replacement (AVR) showing non-inferiority to standard stented aortic valves for major cardiovascular and cerebral events at 1-year. We report the 1-year hemodynamic performance of the sutureless prostheses compared with standard aortic valves, assessed by a dedicated echocardiographic core lab.

Methods

Perceval Sutureless Implant vs. Standard Aortic Valve Replacement (PERSIST-AVR) is a prospective, randomized, adaptive, open-label trial. Patients undergoing AVR, as an isolated or combined procedure, were randomized to receive a sutureless [sutureless aortic valve replacement (Su-AVR)] (n = 407) or a stented sutured [surgical AVR (SAVR)] (n = 412) bioprostheses. Site-reported echocardiographic examinations were collected at 1 year. In addition, a subgroup of the trial population (Su-AVR n = 71, SAVR = 82) had a complete echocardiographic examination independently assessed by a Core Lab (MedStar Health Research Institute, Washington D.C., USA) for the evaluation of the hemodynamic performance.

Results

The site-reported hemodynamic data of stented valves and sutureless valves are stable and comparable during follow-up, showing stable reduction of mean and peak pressure gradients through one-year follow-up (mean: 12.1 ± 6.2 vs. 11.5 ± 4.6 mmHg; peak: 21.3 ± 11.4 vs. 22.0 ± 8.9 mmHg). These results at 1-year are confirmed in the subgroup by the core-lab assessed echocardiogram with an average mean and peak gradient of 12.8 ± 5.7 and 21.5 ± 9.1 mmHg for Su-AVR, and 13.4 ± 7.7 and 23.0 ± 13.0 mmHg for SAVR. The valve effective orifice area was 1.3 ± 0.4 and 1.4 ± 0.4 cm2 at 1-year for Su-AVR and SAVR. These improvements are observed across all valve sizes. At 1-year evaluation, 91.3% (n = 42) of patients in Su-AVR and 82.3% in SAVR (n = 51) groups were free from paravalvular leak (PVL). The rate of mild PVL was 4.3% (n = 2) in Su-AVR and 12.9% (n = 8) in the SAVR group. A similar trend is observed for central leak occurrence in both core-lab assessed echo groups.

Conclusion

At 1-year of follow-up of a PERSIST-AVR patient sub-group, the study showed comparable hemodynamic performance in the sutureless and the stented-valve groups, confirmed by independent echo core lab. Perceval sutureless prosthesis provides optimal sealing at the annulus with equivalent PVL and central regurgitation extent rates compared to sutured valves. Sutureless valves are therefore a reliable and essential technology within the modern therapeutic possibilities to treat aortic valve disease.

Changes in the Prosthesis Types Used for Aortic Valve Replacement after the Introduction of Sutureless and Rapid Deployment Valves in Korea: A Nationwide Population-Based Cohort Study

Background

Sutureless and rapid deployment valves for aortic valve replacement (AVR) were introduced in Korea in December 2016. This study evaluated changing trends in the prosthetic valves used for AVR in Korea after the introduction of sutureless and rapid deployment valves.

Methods

From December 2016 to December 2018, 4,899 patients underwent AVR in Korea. After applying the exclusion criteria, 4,872 patients were analyzed to determine changes in the type of prosthetic valve used for AVR. The study period was divided into 5 groups corresponding to 5-month intervals.

Results

The total number of AVR cases was 194.88±28.78 per month during the study period. Mechanical valves were used in approximately 27% to 33% of cases, and the proportion of mechanical valve use showed a tendency to decrease, with marginal significance overall (p=0.078) and significant decreases in patients less than 60 years of age and in men (p=0.013 and p=0.023, respectively). The use of sutureless valves increased from 13.4% to 25.8% of cases (p<0.001), especially in elderly patients (>70 years) and those requiring concomitant surgery. In a comparison between sutureless and rapid deployment valves, the use of Perceval S valves (a type of sutureless valve), gradually increased (p<0.001).

Conclusion

After the introduction of sutureless and rapid deployment valves in Korea, the rate of use of these new valves remarkably increased, especially in elderly patients and those requiring concomitant surgery. Further studies should investigate the clinical outcomes of these new prostheses.

Early conduction disorders after aortic valve replacement with the sutureless Perceval prosthesis

BACKGROUND

To determine the incidence of postoperative conduction disorders and need for pacemaker implantation after aortic valve replacement(AVR) with the Perceval prosthesis.

METHODS

From January 2007 to December 2017, 908 patients underwent AVR with Perceval S in 5 participating centers. Study endpoints focused on electrocardiographic changes after AVR and the incidence of new pacemaker(PM) implantation in 801 patients after exclusion of patients with previous PM(n=48) or patients undergoing tricuspid(n=28) and/or AF ablation(n=31) surgery. Logistic regression analysis was performed to determine risk factors for PM need.

RESULTS

Mean age was 79.7±5.2 years, 476(59.4%) were females. Median logistic Euroscore II was 4.1%(IQR 2.6-6.0). Isolated AVR was performed in 441(55.1%) patients. Associated procedures were CABG(n=309, 38.6%) and mitral valve surgery(n=51, 6.4%). Overall 30d-mortality was 3.9%, and 2.8% for isolated AVR. Electrocardiographic changes included a significant increase of LBBB (7.4 to 23.7%, p<0.001) and development of complete AV block, requiring PM implantation in 9.5%. Multivariable analysis revealed independent of a learning period(OR 1.91, 95%CI 1.16-3.13, p=0.011), pre-existing RBBB(OR 2.77, 95%CI 1.40-5.48, p=0.003), intra-operative prosthesis repositioning(OR 6.70, 95%CI 1.89-24.40, p=0.003) and size XL(OR 6.81, 95%CI 1.55-29.96, p=0.011) as significant predictors of PM implantation.

CONCLUSIONS

In a challenging elderly population, use of the Perceval S for AVR provides low operative mortality, but at the risk of an increased PM implantation rate. Besides to pre-existing right-bundle branch block, the significant effect of size XL, an increased valve size/BSA ratio and need for intra-operative repositioning on PM rate are underscoring the reappraisal of the annular sizing policy.

Clinical and Hemodynamic Outcomes in 121 Patients Who Underwent Perceval Sutureless Aortic Valve Implantation - Early Results From a Single Korean Institution

BACKGROUND

This study aimed to evaluate the early outcomes of Perceval sutureless valves in the Korean population and to introduce a modified technique of guiding suture placement during valve deployment.

METHODS AND RESULTS

From December 2014 to April 2019, 121 patients (mean age: 74.7±6.2 years; 53.7% female) received a Perceval sutureless aortic valve replacement. To prevent conduction system injury, the depth of guiding suture placement (1 mm below the nadir of the annulus) was modified. All patients underwent echocardiographic evaluation at discharge and 6-12 months postoperatively, with a mean follow up of 13.7±11.2 months. Concomitant surgeries, such as coronary artery bypass grafting, and other valvular surgeries, were performed in 45.5% of cases. The mean aortic cross-clamp times for isolated and minimal procedures were 32.8±7.9, and 41.2±8.0 min, respectively. The overall transvalvular mean gradients were 13.1±3.8 mmHg at discharge and 11.5±4.7 mmHg at the last follow up. After modifying the guiding suture placement, permanent pacemaker implantation risk decreased from 9.9% to 2.5%. Cardiac-related mortality was 0.8%, with no patient developing valvular or paravalvular aortic regurgitation, valve thrombosis, or endocarditis.

CONCLUSIONS

Perceval valve implantation provided a significant cardiac-related survival benefit with excellent early hemodynamic and clinical outcomes. Further research is needed to determine whether adjusting the implantation depth, such as modification of the guiding suture technique, can reduce the risk of permanent pacemaker implantation.

Sutureless aortic valve replacement in multivalve procedures

Background

Despite the rapid expansion of transcatheter approaches for aortic valve implantation, surgical aortic valve replacement remains the treatment of choice in patients presenting with multiple valvular heart disease. We sought to review our clinical experience with sutureless aortic valve replacement (SU-AVR) in the setting of multivalve procedures, addressing the postoperative outcomes and technical challenges.

Methods

Between December 2019 and December 2020, 20 consecutive high-risk patients at our institution underwent SU-AVR and concomitant mitral valve procedure for various indications.

Results

The mean age of the patients at operation was 72.6±9.3 years. Fifty five percent of the patients (n=11) presented with moderate to severe symptomatic aortic valve stenosis, while 35% (n=7) suffered from severe aortic regurgitation. All patients had concomitant moderate to severe mitral valve disease, including regurgitation in 95% (n=19) and stenosis in 25% (n=5). Mean logistic EuroSCORE was 34.3%±24.7%. Cardiopulmonary bypass and cross-clamp times were 101 (88.0-123) minutes and 67.5 (51.7-85.2) minutes, respectively. Optimal sutureless aortic valve prosthesis device success was achieved in 20 patients (100%). One patient (5%) required permanent pacemaker implantation. Thirty-day mortality was 10% and no strokes were detected.

Conclusions

SU-AVR is a safe and feasible surgical alternative to conventional procedures in patients presenting with multiple valvular heart disease. It provides excellent hemodynamic performance with low risk of paravalvular leakage and low transvalvular gradients, whilst simplifying the surgical procedure. Precise sizing and positioning of the valve prostheses is crucial to ensure optimal postoperative outcome.

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.

A pooled analysis of pacemaker implantation after Perceval sutureless aortic valve replacement

 

OBJECTIVES

We performed a literature meta-analysis to estimate the rate of pacemaker implantation after Perceval sutureless aortic valve replacement.

METHODS

Pertinent articles were identified from the PubMed, Google Scholar, Ovid MEDLINE and Ovid EMBASE databases. Eligible studies reported the de novo incidence of postoperative pacemaker implantation after Perceval valve surgery. Among 394 articles retrieved, 26 studies including 9492 patients met the inclusion criteria.

RESULTS

The pooled event rate for postoperative pacemaker implantation was 7% [95% confidence interval (CI) 6-9%]; however, significant heterogeneity was observed across studies. In a sub-analysis, there was no difference between the rates of pacemaker implantation calculated from multicentre and registry studies (8 studies, 6845 patients; 7%, 95% CI 5-10%) and single-centre studies (18 studies, 2647 patients; 7%, 95% CI 5-9%; P = 0.75). Implantation rates were similar in high-volume studies (16 studies, 9121 patients; 7%, 95% CI 5-8%) than in low-volume studies (10 studies, 371 patients; pooled rate: 7%, 95% CI 4-14%; P = 0.5). Postoperative pacemaker implantation rates tended to decrease over time.

CONCLUSIONS

With a pooled event rate of 7%, postoperative pacemaker implantation remains an important limitation of Perceval sutureless valve surgery, although we observed a degree of variability across included studies. The resultant findings provide a useful estimate for physicians and patients and can serve as a benchmark for future comparative studies.

PROSPERO REGISTRATION NUMBER

CRD42020188397.

Sutureless aortic valves in elderly patients with aortic stenosis and intermediate-risk profile

AIMS

Sutureless valves became an alternative to standard bioprostheses, allowing surgeons to significantly reduce cross-clamping and extracorporeal circulation times, with a potential positive impact on major postoperative complications. The aim of this European multicentre study was to evaluate the safety and efficacy of sutureless valves in patients with an intermediate-risk profile undergoing aortic valve replacement (AVR).

METHODS

We investigated early and mid-term outcomes of 518 elderly patients with aortic stenosis at intermediate-risk profile (mean STS Score 6.1 ± 2%) undergoing AVR with sutureless aortic valve. Primary endpoints were 30-day mortality and freedom from all-cause death at follow-up. The secondary endpoint was survival freedom from MACCEs [all-cause death, stroke/transitory ischemic attack (TIA), bleeding, myocardial infarction, aortic regurgitation Grade II, endocarditis, reintervention and pacemaker implant; VARC 1--2 criteria].

RESULTS

Sutureless valve implantation was successfully performed in 508 patients, with a procedural success rate of 98.1% (508/518) as per VARC criteria. Concomitant myocardial revascularization [coronary artery bypass grafting (CABG)] was performed in 74 out of 518 patients (14.3%). In-hospital mortality was 1.9% (10/518). Postoperative complications included revision for bleeding (23/518; 4.4%), prolonged intubation more than 48h (4/518; 0.7%), acute renal failure (14/518; 2.7%), stroke/TIA (11/518; 2.1%), pacemaker implantation (26/518; 5.1%) and aortic regurgitation more than Grade II (7/518; 1.4%). At 48-month follow-up, Kaplan-Meier overall survival and freedom from MACCEs in patients receiving isolated AVR were 83.7% [95% confidence interval (95% CI): 81.1-86.3] and 78.4% (95% CI: 75.5-81.4), respectively, while in patients with concomitant CABG, Kaplan-Meier overall survival and freedom from MACCEs were 82.3% (95% CI: 73.3-91.3) and 79.1% (95% CI: 69.9-88.3), respectively.

CONCLUSION

The use of sutureless aortic valves in elderly patients with an intermediate-risk profile provided excellent early and mid-term outcomes, providing a reliable tool in patients undergoing surgical AVR in this specific subset of population. These preliminary data need to be investigated with a TAVI control-group in further studies.

Early and Two-year Outcomes after Sutureless and Conventional Aortic Valve Replacement: a Nationwide Population-based Study

BACKGROUND

We compared early and 2-year clinical outcomes of sutureless aortic valve replacement (SAVR) with conventional aortic valve replacement (CAVR) in a nationwide study based on claims data.

METHODS

From December 2016 to November 2018, 3,173 patients underwent bioprosthetic aortic valve replacements. SAVR and CAVR were performed in 641 and 2,532 patients, respectively. Propensity score-matched analysis was performed in 640 patient pairs.

RESULTS

Operative mortality rate was 2.8% without significant differences between the SAVR (3.4%) and CAVR (2.3%) groups (P = 0.324). There were no significant differences in postoperative morbidities between the groups except for permanent pacemaker (PPM) implantation. PPM implantation rate was significantly higher in the SAVR (3.8%) than in the CAVR group (0.9%) (P < 0.001). One- and two-year overall survival was 89.1% and 87.5%, respectively, without significant differences between the groups (SAVR group vs. CAVR grouP = 89.9% and 90.5% vs. 87.2% and 88.7%, respectively; P = 0.475). There were no significant differences in the cumulative incidence of cardiac death, stroke, aortic valve reoperation and infective endocarditis between the groups. Cumulative PPM implantation incidence at 6 months in the CAVR was 1.1%, and no patient required PPM implantation after 6 months. In the SAVR, the cumulative PPM implantation incidence at 0.5, one, and two years was 3.9%, 5.0% and 5.6%, respectively. The cumulative PPM implantation rate was higher in the SAVR group than in the CAVR group (P < 0.001).

CONCLUSION

Early and 2-year clinical outcomes between SAVR and CAVR were not different except for a high rate of permanent pacemaker implantation in the SAVR group.

Minimally invasive aortic valve replacement with sutureless bioprosthesis through right minithoracotomy with completely central cannulation-Early results in 203 patients

OBJECTIVES

Minimally invasive aortic valve replacement (mini-AVR) might improve clinical outcomes, particularly in high-risk and elderly patients. Sutureless/rapid deployment bioprosthesis can offer advantage of decreasing the cross-clamp time (XCT) and easing the procedure. Our aim was to evaluate the safety and perioperative outcomes of mini-AVR using sutureless bioprothesis via the right minithoracotomy approach with our modified technique of central cannulation.

METHODS

We performed a single-center retrospective analysis of 203 patients consecutively undergoing isolated AVR between March 2016 and June 2018 with the right minithoracotomy approach and our modified technique of central cannulation. Aortic valve diseases were stenosis (89.9%), regurgitation (1.6%), and mixed valve disease (8.5%). Patients with concomitant procedures were excluded. Primary endpoints were 30-day and 4-month mortality.

RESULTS

Mean age was 76 ± 6.2 years, 63 (31%) patients were 80 years or older. Cardiopulmonary bypass and XCT were 60.5 (39-153) and 35 (24-76) min, respectively. Thirty-day and 4-month mortality were 1% (two patients). We have observed minor paravalvular leak (PVL) which occurred in seven patients (3.4%), and no moderate/severe PVL was found perioperatively. One patient developed moderate/severe PVL during the 4-month follow-up. There was no structural valve degeneration. Two (1%) patients needed conversion to full sternotomy, and two (1%) patients to ministernotomy.

CONCLUSIONS

Mini-AVR via the right minithoracotomy approach with central cannulation is an effective and safe procedure and demonstrates excellent early clinical outcomes. This approach can be particularly valuable in higher risk and elderly patients.

Mid-term assessment of structural valve deterioration of perceval S sutureless prosthesis using the last European consensus definition

OBJECTIVES

Durability of sutureless aortic bioprosthetic valves remains a major issue. The aim of this study was to assess structural valve deterioration (SVD) and bioprosthetic valve failure (BVF) of the Perceval bioprosthesis using the new proposed standardized definitions.

METHODS

All patients who underwent aortic valve replacement with sutureless Perceval S prostheses up to September 2016 were included. Clinical and echocardiographic follow-up was performed. New standardized definitions were used to assess the durability of sutureless bioprosthetic valves. From 2013 to 2016, 214 patients were included.

RESULTS

The mean age and EuroSCORE II were 79 years and 2.74. Thirty-day mortality was 0.47%. The survival rate was 96.8%, 88.1% and 85.7% at 1, 3 and 4 years, respectively. The median echocardiographic follow-up was 3.28 years. The mean pressure gradient was 11.3 mmHg. No cases showed evidence of severe SVD, 17 patients had moderate SVD with a mean pressure gradient of 24 mmHg and 8 patients had definite late BVF. The incidence of moderate SVD and BVF at 4 years was 8.8% and 2.9%, respectively.

CONCLUSIONS

Mid-term follow-up to 6.3 years after aortic valve replacement with the Perceval bioprosthesis documents favourable haemodynamic and clinical outcomes and low rates of SVD and BVF.

ValveTech: A Novel Robotic Approach for Minimally Invasive Aortic Valve Replacement

OBJECTIVE

Aortic valve disease is the most common heart disease in the elderly calling for replacement with an artificial valve. The presented surgical robot aims to provide a highly controllable instrument for efficient delivery of an artificial valve by the help of integrated endoscopic vision.

METHODS

A robot (called ValveTech), intended for minimally invasive surgery (MIS) and consisting of a flexible cable driven manipulator, a passive arm, and a control unit has been designed and prototyped. The flexible manipulator has several features (e.g., stabilizing flaps, tiny cameras, dexterous introducer and custom cartridge) to help the proper valve placement. It provides 5 degrees of freedom for reaching the operative site via mini-thoracotomy; it adjusts the valve and expands it at the optimal position. The robot was evaluated by ten cardiac surgeons following a real surgical scenario in artificial chest simulator with an aortic mockup. Moreover, after each delivery, the expanded valve was evaluated objectively in comparison with the ideal position.

RESULTS

The robot performances were evaluated positively by surgeons. The trials resulted in faster delivery and an average misalignment distance of 3.8 mm along the aorta axis; 16.3 degrees rotational angle around aorta axis and 8.8 degrees misalignment of the valve commissure plane to the ideal plane were measured.

CONCLUSION

The trials successfully proved the proposed system for valve delivery under endoscopic vision.

SIGNIFICANCE

The ValveTech robot can be an alternative solution for minimally invasive aortic valve surgery and improve the quality of the operation both for surgeons and patients.

Attempt at off-label balloon valvuloplasty post-dilation for intuity sutureless valve

Alternatives to traditional aortic valve replacement now form part of the valve surgeon's armamentarium. Sutureless valves offer decreased bypass and crossclamp times, excellent maneuverability, and promising outcomes. We present a case of a sutureless aortic valve replacement for a late failed David procedure, complicated by postoperative development of severe paravalvular regurgitation. We attempted off-label balloon post-dilation to improve expansion of the valve, however paravalvular regurgitation persisted. The patient underwent subsequent aortic valve replacement using a mechanical valve and experienced no further paravalvular leak.

Right anterior mini-thoracotomy and sutureless valves: the perfect marriage

Background

A minimally invasive approach (MIA) reduces mortality and morbidity in patients referred for aortic valve replacement (AVR). Sutureless technology facilitates a MIA. We describe our experience with the sutureless Perceval (LivaNova, Italy) aortic bioprosthesis through a right anterior mini-thoracotomy (RAMT) approach.

Methods

Between March 2011 and October 2019, 1,049 patients underwent AVR with Perceval bioprosthesis. Five hundred and three patients (48%) were operated through a RAMT approach in the second intercostal space. Considering only isolated AVR (881), 98% of patients were operated with MIA, and Perceval in RAMT approach was performed in 57% of these patients. Eight patients (1.6%) had previously undergone cardiac surgery. The prosthesis sizes implanted were: S (n=91), M (n=154), L (n=218) and XL (n=40). Concomitant procedures were mitral valve surgery (n=6), tricuspid valve repair (n=1), mitral valve repair and tricuspid valve repair (n=1) and miectomy (n=2). Mean age was 78±4 years (range, 65-89 years), 317 patients were female (63%) and EuroSCORE II was 5.9%±8.4%.

Results

The 30-day mortality was 0.8% (4/503). Cardiopulmonary bypass (CPB) and aortic cross-clamp times were 81.6±30.8 and 50.3±24.5 minutes respectively for stand-alone procedures. In two patients, early moderate paravalvular leakage appeared as a result of incomplete expansion of the sutureless valve due to oversizing of the bioprosthesis, requiring reoperations at two and nine postoperative days with sutured aortic bioprosthesis implantation. Permanent pacemaker implantation within the first thirty days was necessary in 26 (5.2%) patients. At the mean follow-up of 4.6 years (range, 1 month to 8.6 years), survival was 96%, freedom from reoperation was 99.2%, and mean transvalvular pressure gradient was 11.9±4.3 mmHg.

Conclusions

AVR with the Perceval bioprosthesis in a RAMT approach is a safe and feasible procedure associated with low mortality and excellent hemodynamic performance. Sutureless technology facilitates a RAMT approach.

Sutureless aortic valve replacement with concomitant aortic arch reconstruction

Sutureless aortic valve replacement (AVR) offers an alternative approach to the standard AVR in aortic valve disease. We herein report a case of an 82-year-old woman with severe aortic insufficiency and a persistent type 1 endoleak following a thoracic endovascular aortic repair, who underwent successful combined aortic arch reconstruction and sutureless AVR. The bioprosthesis, Perceval (LivaNova PLC, London, UK), a self-anchoring, self-expanding, sutureless valve, which can be implanted in selected patients with aortic insufficiency was used. Although the patient was frail and at a high risk of open-heart surgery, she had an uneventful postoperative course. Hence, Perceval may be a useful option for combined aortic arch reconstruction and aortic valve surgery in high-risk elderly patients.

Safety and Haemodynamic Outcomes of Currently Available Suture-less Aortic Valves in Patients With Aortic Stenosis: A Meta-Analysis

BACKGROUND

Suture-less aortic valves aim to achieve better outcomes and to aid and facilitate the minimally invasive aortic valve replacement procedure by tackling the issue of cross-clamp time, which is an independent predictor of postoperative outcomes, especially in patients with serious comorbidities. By reducing the number of sutures, the time for suture placement is reduced. Our meta-analysis tried to assess the safety and haemodynamic performance of the suture-less aortic valve prostheses to ascertain their benefits as a viable alternative to current established measures.

METHOD

From their inceptions to February 2017, six electronic databases were searched. Relevant studies using commercially accessible suture-free valves to replace the aortic valve have been recognised. Based on the predefined endpoints, data were collected and analysed.

RESULTS

For incorporation in qualitative and quantitative analyses, 24 studies were recognised, with a total number of 5,073 patients undergoing suture-less aortic valve replacement. Mortality incidence at the 30-day and 12-month follow-ups were 2.5% and 2.7%, respectively, while the incidences of thromboembolic events (1.6%) and paravalvular leak (0.5%) were acceptable.

CONCLUSIONS

Current available evidence indicates that sutureless aortic valve replacement is a safe operation showing low mortality and complication rates, with satisfactory haemodynamic performance.

Positioning and stiffening of an articulated/continuum manipulator for implant delivery in minimally invasive surgery

BACKGROUND

Hollow, bendable manipulators can advance implant delivery in minimally invasive surgery, by circumventing the drawbacks of straight-line delivery and fostering single-port approaches. Variable stiffness manipulators are sought to be safe and effective.

METHODS

We designed and experimentally assessed a cable-driven articulated/continuum manipulator, devised for cardiac valve delivery. Positioning and stiffening were teleoperated, based on cable shortening. Stiffening was parameterized by using the leading tension (LT, ie, tension of the cables driving bending). We assessed positioning (repeatability/reversibility along eight/two bending directions) and stiffening (eight bent configurations).

RESULTS

We achieved good repeatability and reversibility (mean errors <1% and 1.5%, respectively, of the workspace characteristic length). Stiffening was effective (up to 9-fold increase, depending on pose). Stiffening was linearly correlated (R² = 0.92) with LT for all the considered configurations.

CONCLUSION

We accurately positioned and effectively stiffened the manipulator in several bent configurations. The proposed stiffness modulation strategy can be extended to other manipulators.

Minimally Invasive Aortic Valve Replacement with Sutureless Valves: Results From an International Prospective Registry

Objective

To report the early and mid-term results of patients who underwent minimally invasive aortic valve replacement (MI-AVR) with a sutureless prosthesis from an international prospective registry.

Methods

Between March 2011 and September 2018, among 957 patients included in the prospective observational SURE-AVR (Sorin Universal REgistry on Aortic Valve Replacement) registry, 480 patients underwent MI-AVR with self-expandable Perceval aortic bioprosthesis (LivaNova PLC, London, UK) in 29 international institutions through either minithoracotomy ( n = 266) or ministernotomy ( n = 214). Postoperative, follow-up, and echocardiographic outcomes were analyzed for all patients.

Results

Patient age was 76.1 ± 7.1 years; 64.4% were female. Median EuroSCORE I was 7.9% (interquartile range [IQR], 4.8 to 10.9). Median cardiopulmonary bypass and cross-clamp times were 81 minutes (IQR 64 to 100) and 51 minutes (IQR 40 to 63). First successful implantation was achieved in 97.9% of cases. Two in-hospital deaths occurred, 1 for noncardiovascular causes and 1 following a disabling stroke. In the early (≤30 days) period, stroke rate was 1.4%. Three early explants were reported: 2 due to nonstructural valve dysfunction (NSVD) and 1 for malpositioning. One mild and 1 moderate paravalvular leak were reported. In 16 patients (3.3%) pacemaker implantation was needed. Mean follow-up was 2.4 years (maximum = 7 years). During follow-up 5 explants were reported, 3 due to endocarditis and 2 due to NSVD. Follow-up stroke rate was 2.5%. Three structural valve deteriorations not requiring reintervention were reported. Five-year survival was 91.45%.

Conclusions

In this large prospective international registry, MI-AVR with Perceval valve confirmed to be safe, reproducible, and effective in an intermediate-risk population, providing excellent clinical recovery both in early and mid-term follow-up.

Immediate and long-term need for permanent cardiac pacing following aortic valve replacement

Introduction: Atrioventricular (AV) node conduction disturbances are common following surgical aortic valve replacement (SAVR), and in some cases the patient needs a permanent pacemaker (PPM) implantation before discharge from hospital. Little is known about the long-term need for PPM and the PPM dependency of these individuals. We determined the incidence of PPM implantation before and after discharge in SAVR patients. Methods: We studied 557 consecutive patients who underwent SAVR for aortic stenosis in Iceland between 2002 and 2016. Timing and indication for PPM were registered, with a new concept, ventricular pacing proportion (VPP), defined as ventricular pacing ≥90% of the time, being used to approximate pacemaker dependency. The median follow-up time was 73 months. We plotted the cumulative incidence of pacemaker implantation, treating death as a competing risk. Results: Of the 557 patients, 22 (3.9%) received PPM in the first 30 days after surgery, most commonly for complete AV block (n = 14) or symptomatic bradycardia (n = 8); Thirty-eight other patients (6.8%) had a PPM implanted >30 days postoperatively, at a median of 43 months after surgery (range 0‒181), most often for AV block (n = 13) or sick-sinus syndrome (n = 10). The cumulative incidence of PPM implantation at 1, 5, and 10 years postoperatively was 5.0%, 9.2%, and 12.3%, respectively. During follow-up, 45.0% of the 60 patients had VPP ≥90%. Conclusion: The cumulative incidence of permanent pacemaker implantation following SAVR was about 12% at 10 years, with every other patient having VPP ≥90% during follow-up. This suggests that AV node conduction disturbances extend significantly beyond the perioperative period.

Paravalvular Leaks-From Diagnosis to Management

PURPOSE OF REVIEW

As the number of surgical and transcatheter valve replacements continue to increase in the aging population, so does the incidence of paravalvular leak (PVL). Given its impact on morbidity and mortality, this article will focus on the epidemiology, clinical presentation, diagnostic assessment, and available treatments for PVL.

RECENT FINDINGS

Despite being performed on inoperable and typically higher risk patients, short-term complication rates of transcatheter PVL closure appear relatively low (< 10%). When indirectly compared with surgical PVL closure, long-term mortality, reoperation rates and degree of symptom improvement are similar. Nonetheless, current transcatheter closure devices are off-label and repurposed from other indications. Further development of percutaneous closure devices is an essential next step in order to improve and optimize outcomes. In patients with surgical and especially transcatheter-replaced heart valves, clinicians need to maintain vigilance for the presence of PVL, particularly in those with new-onset heart failure or hemolysis. Multimodality imaging is essential to detect and quantify PVL. Echocardiography (both transthoracic and transesophageal) is the backbone of diagnosis and quantification, and cardiac computed tomography and cardiac magnetic resonance imaging play an important role in defect characterization and in periprocedural planning. For those patients who are unable to undergo surgery, transcatheter PVL closure is an appropriate next step in management as it has similar outcomes to surgical intervention when performed in a center of expertise.

Improved long-term outcome of surgical AVR for AS: Results from a population-based cohort

BACKGROUND

The aim of this retrospective study was to determine changes in outcomes after surgical aortic valve replacement (SAVR) for aortic stenosis (AS) in Iceland over a 15-year period.

METHODS

We included 587 patients who underwent SAVR for AS in Iceland during the period 2002-2016, with a total follow-up of 3245 patient-years. Short-term and long-term outcomes, 30-day mortality, and long-term survival (Kaplan-Meier) were analyzed. Univariate linear regression and univariate and multinomial logistic regression analyses were performed on preoperative and perioperative variables. Poisson regression analysis was used to evaluate changes in rates of short-term outcomes.

RESULTS

Mean age was 71 years, 65.1% were males, and mean EuroSCORE II was 3.9. Mean preoperative aortic valve area increased significantly (0.013 cm² /year; P < .001) and mean aortic cross-clamp time declined (108 minutes, 2.8 min/year; P < .001). The rate of complications decreased, including new-onset atrial fibrillation (60.9% overall, decreased by 3.1%/year, P = .02), acute kidney injury (17.1%, 7.6%/year, P < .001), and reoperation for bleeding (12.5%, 6.3%/year, P = .02). Operative mortality did not change (5.4%); nor did 1- and 5-year overall survival (92.5% and 81.6%, respectively). Notable long-term events were chronic heart failure (27.7 admissions/100 patient-years), embolic event (15.9/100 patient-years), and bleeding (13.0/100 patient-years).

CONCLUSIONS

Results of SAVR in this well-defined nationwide cohort of patients in Iceland have improved. This may be related to the patients having less severe AS at the time of operation and shorter operating times, as reflected by lower rates of short-term complications. However, the rate of long-term complications did not change significantly, with prosthetic valve-specific events being rare.

Cardiac prostheses-related hemolytic anemia

Hemolysis is an unintended sequel of temporary or permanent intracardiac devices. However, limited data exist on the characteristics and treatment of hemolysis in patients with cardiac prostheses. This entity, albeit uncommon, often poses significant diagnostic and management challenges to the clinical cardiologist. In this article, we aim to provide a contemporary overview of the incidence, mechanisms, diagnosis, and management of cardiac prosthesis‐related hemolysis.

Replacement of a Stenotic Quadricuspid Aortic Valve With a Sutureless Prosthesis

Quadricuspid aortic valve is a rare occurrence, usually presenting with insufficiency rather than stenosis. We report an aortic valve replacement in a septuagenarian with a stenotic quadricuspid aortic valve, achieving a good result with a Perceval (Sorin Biomedica Cardio Srl, Sallugia, Italy) sutureless bioprosthesis. We emphasize the particular technique of implantation and possible pitfalls. Sutureless bioprosthetic valves present a feasible option for aortic valve replacement in patients with uncommon valve morphologies, aiming to reduce operative time.