The rise of new technologies for aortic valve stenosis: A comparison of sutureless and transcatheter aortic valve implantation

Hemodynamic Performance of Transcatheter Aortic Valves: A Comprehensive Review

Transcatheter aortic valve implantation (TAVI) is a widely adopted treatment option for patients with severe aortic stenosis. Its popularity has grown significantly in recent years due to advancements in technology and imaging. As TAVI use is increasingly expanded to younger patients, the need for long-term assessment and durability becomes paramount. This review aims to provide an overview of the diagnostic tools to evaluate the hemodynamic performance of aortic prosthesis, with a special focus on the comparison between transcatheter and surgical aortic valves and between self-expandable and balloon-expandable valves. Moreover, the discussion will encompass how cardiovascular imaging can effectively detect long-term structural valve deterioration.

The hemodynamic performance of balloon-expandable aortic bioprostheses in the elderly: a comparison between rapid deployment and transcatheter implantation

BACKGROUND

Surgical aortic valve replacement with a rapid deployment valve (RDV) is a relatively recent treatment option. Aim of this study was to compare the hemodynamic performance of balloon-expandable (BE)-RDVs and BE-transcatheter heart valves (THVs) in a high surgical risk and frail-elderly population.

METHODS

BE-THVs and BE-RDVs were respectively implanted in 138 and 47 patients, all older than 75 years and with a Canadian Study of Health and Aging category of 5 or above. Echocardiographic assessment was performed at discharge and at six months.

RESULTS

At discharge, transprosthetic pressure gradients and indexed effective orifice area (iEOA) were similar in both cohorts. At six-month follow-up, BE-RDV showed lower peak (14.69 vs 20.86 mmHg; p <0.001) and mean (7.82 vs 11.83 mmHg; p <0.001) gradients, as well as larger iEOA (1.05 vs 0.84 cm²/m²; p <0.001). Similar findings were also shown considering only small sized valves. Moderate-to-severe paravalvular leakage was more prevalent in BE-THVs at discharge (14.49 vs 0.00%; p=0.032) and, considering exclusively small prostheses, at six months too (57.69 vs 15.00%; p=0.014). Nevertheless, BE-THVs determined amelioration in left ventricular ejection fraction (53.79 vs 60.14%; p <0.001), pulmonary artery systolic pressure (35.81 vs 33.15 mmHg; p=0.042) and tricuspid regurgitation severity (40.58 vs 19.57%; p=0.031) from discharge to mid-term follow-up.

CONCLUSIONS

BE-RDVs showed better hemodynamic performance, especially when implanted in small annulus. Despite their worse baseline conditions, transcatheter patients still exhibited a greater improvement of their echocardiographic profile at mid-term follow-up.

Early and late outcomes of surgical aortic valve replacement with sutureless and rapid-deployment valves versus transcatheter aortic valve implantation: Meta-analysis with reconstructed time-to-event data of matched studies

Sutureless/rapid-deployment (SURD) valves are options different from the stented prostheses included in the pivotal trials comparing surgical aortic valve replacement (AVR) and transcatheter aortic valve implantation (TAVI). We performed a meta-analysis with reconstructed time-to-event data of matched studies published by November 2021 to compare SURD-AVR and TAVI. Primary endpoints were 30-day mortality and overall survival in the follow-up. Secondary endpoints included: 30-day stroke, acute kidney injury (AKI), major bleeding, permanent pacemaker implantation (PPI), paravalvular leak (PVL), prosthesis-patient mismatch (PPM), postoperative aortic valve area (AVA), and mean gradients. Ten studies met our eligibility criteria, including a total of 5134 patients (2567 underwent SURD-AVR and 2567 underwent TAVI). Pooled risk of 30-day mortality did not favor any group (odds ratio [OR]: 0.69; 95% confidence interval [CI]: 0.31-1.53; p = 0.360). Patients undergoing SURD-AVR had lower risk of PVL (OR: 0.09; 95% CI: 0.05-0.17; p < 0.001). No statistically significant differences were observed for 30-day stroke, AKI, major bleeding, PPI, PPM, and postoperative AVA. In the follow-up, we observed a higher risk of mortality (hazard ratio: 1.74; 95% CI: 1.26-2.40; p < 0.001) with TAVI. Patients who underwent SURD-AVR experienced better survival, however, the interpretation of these results warrant caution due to the fact that SURD-AVR patients tended to be younger than TAVI patients. Structural heart surgeons and interventional cardiologists should consider initial risk and life expectancy when referring patients for one approach over the other.

Outcomes of sutureless aortic valve replacement versus conventional aortic valve replacement and transcatheter aortic valve replacement, updated systematic review, and meta-analysis

BACKGROUND

Sutureless aortic valve replacement (SuAVR) is an alternative to surgical aortic valve replacement (SAVR) and transcatheter aortic valve replacement (TAVR). This study compares the effectiveness of SuAVR to SAVR and TAVR.

METHODS

We searched MEDLINE and EMBASE from inception to July 2021 for studies evaluating SuAVR, SAVR, and TAVR in adults with aortic stenosis. We performed screening, full-text assessment, data collection, and risk of bias evaluation independently and in duplicate. We evaluated risk of bias using by Cochrane and CLARITY's tools, and certainty in evidence using the GRADE framework. Data were pooled using a random-effects model.

RESULTS

We identified one randomized and 78 observational studies (n = 60,689; SuAVR vs. SAVR = 39,171, vs. TAVR = 21,518). All studies were at high or unclear risk of bias, with very-low certainty in effect estimates. Compared to TAVR, SuAVR demonstrates no significant difference in mortality at 30-days (odds ratio [OR]: 0.52, 95% confidence interval [CI: 0.85, 1.16], I²  = 0%), but decreased odds at 2-years (OR: 0.39, 95% CI [0.17, 0.88], I²  = 0%). SuAVR also reduced odds of mild paravalvular regurgitation (OR: 0.11, 95% CI [0.06, 0.21], I²  = 50%). Compared to SAVR, SuAVR was associated with a similar mortality at 30-days (OR: 0.99, 95% CI [0.85, 1.16], I²  = 0%) and 2-years (OR: 0.99, 95% CI [0.43-2.30], I²  = 7%). SuAVR significantly increased odds of permanent pacemaker implantation (OR: 2.5, 95% CI [2.25, 2.77], I²  = 0%). Pooled effect estimates were consistent with results from the randomized trial comparing SuAVR and SAVR.

CONCLUSION

Based on very-low quality evidence, SuAVR is associated with similar short- and midterm outcomes compared to TAVR and SAVR. Comparative randomized data with long-term follow-up are required to clarify the role of SuAVR.

Sutureless versus transcatheter aortic valve replacement: A multicenter analysis of "real-world" data

BACKGROUND

Recent data suggested that transcatheter aortic valve replacement (TAVR) may be indicated also for low-risk patients. However, robust evidence is still lacking, particularly regarding valve performance at follow-up that confers a limitation to its use in young patients. Moreover, a literature gap exists in terms of 'real-world' data analysis. The aim of this study is to compare the cost-effectiveness of sutureless aortic valve replacement (SuAVR) versus transfemoral TAVR.

METHODS

Prospectively collected data were retrieved from a centralized database of nine cardiac surgery centers between 2010 and 2018. Follow-up was completed in June 2019. A propensity score matching (PSM) analysis was performed.

RESULTS

Patients in the TAVR group (n=1002) were older and with more comorbidities than SuAVR patients (n=443). The PSM analysis generated 172 pairs. No differences were recorded between groups in 30-day mortality [SuAVR vs TAVR: n=7 (4%) vs n=5 (2.9%); p=0.7] and need for pacemaker implant [n=10 (5.8%) vs n=20 (11.6%); p=0.1], but costs were lower in the SuAVR group (20486.6±4188€ vs 24181.5±3632€; p<0.01). Mean follow-up was 1304±660 days. SuAVR patients had a significantly higher probability of survival than TAVR patients (no. of fatal events: 22 vs 74; p<0.014). Median follow-up was 2231 days and 2394 days in the SuAVR and TAVR group, respectively.

CONCLUSION

The treatment of aortic valve stenosis with surgical sutureless or transcatheter prostheses is safe and effective. By comparing the two approaches, patients who can undergo surgery after heart team evaluation show longer lasting results and a more favorable cost ratio.

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.

Comparison of Self-Expanding RDV Perceval S versus TAVI ACURATE neo/TF

BACKGROUND

 Rapid deployment aortic valve replacement (RDAVR) and transcatheter aortic valve implantation (TAVI) have emerged as increasingly used alternatives to conventional aortic valve replacement to treat patients at higher surgical risk. Therefore, in this single-center study, we retrospectively compared clinical outcomes and hemodynamic performance of two self-expanding biological prostheses, the sutureless and rapid deployment valve (RDV) Perceval-S (PER) and the transcatheter heart valve (THV) ACURATE neo/TF (NEO) in a 1:1 propensity-score-matching (PSM) patient cohort.

METHODS

 A total of 332 consecutive patients with symptomatic aortic valve stenosis underwent either singular RDAVR with PER (119) or TAVI with NEO (213) at our institutions between 2012 and 2017. To compare the unequal patient groups, a 1:1 PSM for preoperative data and comorbidities was conducted. Afterward, 59 patient pairs were compared with regard to relevant hemodynamic parameter, relevant paravalvular leak (PVL), permanent postoperative pacemaker (PPM) implantation rate, and clinical postoperative outcomes.

RESULTS

 Postoperative clinical short-term outcomes presented with slightly higher rates for 30-day all-cause mortality (PER = 5.1% vs. NEO = 1.7%, p = 0.619) and major adverse cardiocerebral event in PER due to cerebrovascular events (transient ischemic attack [TIA]-PER = 3.4% vs. TIA-NEO = 1.7%, p = 0.496 and Stroke-PER = 1.7% vs. Stroke-NEO = 0.0%, p = 1). Moreover, we show comparable PPM rates (PER = 10.2% vs. NEO = 8.5%, p = 0.752). However, higher numbers of PVL (mild-PER = 0.0% vs. NEO = 55.9%, p = 0.001; moderate or higher-PER = 0.0% vs. NEO = 6.8%, p = 0.119) after TAVI with NEO were observed.

CONCLUSION

 Both self-expanding bioprostheses, the RDV-PER and THV-NEO provide a feasible option in elderly and patients with elevated perioperative risk. However, the discussed PER collective showed more postoperative short-term complications with regard to 30-day all-cause mortality and cerebrovascular events, whereas the NEO showed higher rates of PVL.

Implantation of a Sutureless Valve Into a Surgically Enlarged Aortic Root: A Bailout Option

Sutureless bioprostheses such as the Sorin Perceval Valve (SPV; Sorin Group, Srl, Saluggia, Italy) have been proposed for replacing stenotic native valves within small aortic roots of geriatric patients with significant comorbidity. Their use seems as safe as that of stented bioprostheses and enables significantly reduced length of surgery. Low transprosthetic pressure gradients have been measured. Because of the radial force of its self-expandable nitinol stent, aortic annulus interruption could be a relative contraindication to SPV use. Off-label implantation of the SPV into a surgically enlarged ascending aorta was first reported in this study, as a bailout option in the presence of a tiny aortic root.

Minimally Invasive Aortic Valve Replacement on Minimally Invasive Extracorporeal Circulation: Going beyond Aesthetics

We present our multidisciplinary and multistep strategy in patients undergoing minimally invasive aortic valve replacement (mAVR) on minimally invasive extracorporeal circulation (MiECC) compared with control groups of a single strategy and conventional techniques. This cohort study included high-risk patients (Society of Thoracic Surgeons [STS] risk score >8%) undergoing aortic valve surgery under different strategies during the period from January 2017 until March 2019. Patients were matched for age, gender, body mass index, and STS score: group 1 (MiAVR) based on a minimally invasive technique with J-mini-sternotomy, rapid deployment valve (RDV), and type IV customized MiECC; group 2 (control-mAVR) consisted of minimally invasive technique with only J mini-sternotomy and RDV on a conventional extracorporeal system; group 3 (control-MiECC): full sternotomy and type IV customized MiECC; and group 4 (control): full sternotomy on a conventional extracorporeal system. The MiAVR group had significantly less duration of x-clamp time (35.4 ± 11 minutes), postoperative respiratory support (4.1 ± 1 hour), postoperative hemorrhage (250 ± 50 mL), and intensive care unit stay (1 ± .5 days) than the control-conventional (group 4) group. Seventy-six percent of patients did not receive any blood products in MiAVR (p = .025 vs. group 4). Incidence of atrial fibrillation (8%) and low cardiac output (14%) in MiAVR were significantly better than control. Critics of minimally invasive techniques sustain that potential advantages are offset by a longer cross-clamp and cardiopulmonary bypass duration, which may translate into inferior clinical outcomes. We advocate that our multidisciplinary approach supported by multiple technologies may be associated with faster recovery and superior outcomes than conventional minimally/conventional techniques.

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.

Sutureless and Transcatheter Aortic Valve Replacement: When Rivals Become Allies

In recent years, sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve replacement (TAVR) have emerged as viable alternatives to standard surgical aortic valve replacement (AVR) in higher risk patients. We report 7 cases in which SU-AVR and TAVR were used as bailout procedures for each other. Between June 2011 and August 2018, 626 patients underwent SU-AVR with the Perceval S prosthesis, and 588 patients underwent TAVR at the Montreal Heart Institute. Herein, we report the cases of 7 patients who underwent both procedures within a short time frame: 3 patients who underwent SU-AVR with a Perceval prosthesis after a failed TAVR procedure, 3 patients who underwent TAVR after degeneration of a surgically implanted Perceval sutureless prosthesis, and 1 patient who was scheduled for multiple percutaneous interventions-including TAVR, right coronary angioplasty, atrial fibrillation ablation with left atrial appendage occlusion-who suffered a periprocedural complication requiring an emergent surgery, during which a Perceval sutureless prosthesis was deployed. All patients were discharged home alive. Two patients suffered a complete heart block requiring permanent pacemaker implantation. We demonstrate that SU-AVR with the Perceval S prosthesis and TAVR are complementary procedures within the therapeutic armamentarium to treat aortic valve disease in higher risk patients. Specifically, valve-in-valve TAVR is an attractive option in the setting of Perceval prosthesis degeneration, whereas SU-AVR is a useful bailout option in the context of periprocedural failure of a TAVR.

Aortic Valve Replacement in 8 Adults with Anomalous Aortic Origin of Coronary Artery

Patients with anomalous origin of a coronary artery during aortic valve replacement (AVR) are at risk of coronary compromise. Large case series are lacking. In this retrospective study, we review our experience with this condition. From August 2014 through June 2016, 8 adult patients (mean age, 74 ± 17.5 yr; age range, 33-86 yr; 5 men) with anomalous aortic origin of a coronary artery underwent surgical or transcatheter AVR at our institution. Six patients had aortic stenosis; 2 had aortic insufficiency, one of whom had an associated aortic root aneurysm. In 7 patients, the left anomalous coronary artery originated from the right aortic sinus, and in one, the right coronary artery arose from the left cusp. The anatomic course was revealed by means of 3-dimensional computed tomographic angiography. No patient underwent primary aortic reimplantation of the anomalous artery. Two had the artery mobilized from encircling the annulus too closely and then underwent coronary artery bypass grafting. Two high-risk patients underwent transcatheter AVR. After surgical AVR, 2 patients had perioperative myocardial infarction caused by coronary compression, so percutaneous coronary intervention was performed. One patient died of sepsis 3 months after discharge from the hospital. In our patients, AVR sometimes led to severe perioperative complications. Successful AVR depended on 3-dimensional computed tomographic angiographic findings, individual anatomic variations, and appropriate treatment choices.

Comparison of transcatheter aortic valve implantation with other approaches to treat aortic valve stenosis: a systematic review and meta-analysis

BACKGROUND

Transcatheter aortic valve replacement (TAVI) is an alternative treatment for patients with symptomatic severe aortic stenosis ineligible for surgical aortic valve replacement (SAVR) or at increased perioperative risk. Due to continually emerging evidence, we performed a systematic review and meta-analysis comparing benefits and harms of TAVI, SAVR, medical therapy, and balloon aortic valvuloplasty.

METHODS

We searched MEDLINE, Embase, and Cochrane CENTRAL from 2002 to June 6, 2017. We dually screened abstracts and full-text articles for randomized controlled trials (RCTs) and propensity score-matched observational studies. Two investigators independently rated the risk of bias of included studies and determined the certainty of evidence using GRADE (Grading of Recommendations Assessment, Development and Evaluation). If data permitted, we performed meta-analyses using random- and fixed-effects models.

RESULTS

Out of 7755 citations, we included six RCTs (5862 patients) and 13 observational studies (6376 patients). In meta-analyses, patients treated with SAVR or TAVI had similar risks for mortality at 30 days (relative risk [RR] 1.05; 95% confidence interval [CI] 0.82 to 1.33) and 1 year (RR 1.02; 95% CI 0.93 to 1.13). TAVI had significantly lower risks for major bleeding but increased risks for major vascular complications, moderate or severe paravalvular aortic regurgitation, and new pacemaker implantation compared to SAVR. Comparing TAVI to medical therapy, mortality did not differ at 30 days but was significantly reduced at 1 year (RR 0.51; 95% CI 0.34 to 0.77).

CONCLUSIONS

Given similar mortality risks but different patterns of adverse events, the choice between TAVI and SAVR remains an individual one.

Transcatheter, sutureless and conventional aortic-valve replacement: a network meta-analysis of 16,432 patients

Background

Minimally invasive surgical techniques pose alternatives to conventional surgery for the treatment of aortic stenosis (AS). We present a Bayesian network analysis comparing Valve Academic Research Consortium-2 clinical outcomes between transcatheter aortic valve implantation (TAVI), sutureless (SL-AVR) and conventional aortic valve replacement (CAVR).

Methods

Electronic searches of databases were conducted and seven two-arm randomized-controlled trials and 25 propensity-score-matched studies comparing clinical outcomes of TAVI, SL-AVR and CAVR for treatment of AS were identified. Bayesian Markov chain Monte Carlo modelling was used to analyze clinical outcomes.

Results

The analysis included 16,432 patients who underwent TAVI [7,056], SL-AVR [1,238] or CAVR [8,138]. Compared to CAVR, TAVI and SL-AVR were associated with reduced postoperative major bleeding of 59% (OR 0.41, 95% CI: 0.28-0.59) and 44% (OR 0.56, 95% CI: 0.30-0.99) respectively. TAVI had a 41% reduction in postoperative myocardial infarction (OR 0.59, 95% CI: 0.40-0.86) and SL-AVR had a 40% reduction in postoperative acute kidney injury (AKI) (OR 0.62, 95% CI: 0.42-0.86). Compared to TAVI, CAVR and SL-AVR had a reduction in moderate/severe paravalvular regurgitation of 89% (OR 0.11, 95% CI: 0.07-0.16) and 92% (OR 0.08, 95% CI: 0.03-0.17). CAVR had a 67% decreased postoperative permanent pacemaker (PPM) implantation compared to TAVI (OR 0.33, 95% CI: 0.24-0.45) and a 63% reduction compared to SL-AVR (OR 0.37, 95% CI: 0.22-0.61). There were no differences in 30-day mortality or postoperative stroke between the groups.

Conclusions

In selected patients, minimally invasive surgical interventions including TAVI and SL-AVR for severe AS are viable alternatives to conventional surgery. However, TAVI is associated with increased paravalvular regurgitation, whereas TAVI and SL-AVR are associated with increased conduction disturbances compared to CAVR.

Sutureless aortic valves: who is the right patient?

PURPOSE OF REVIEW

Sutureless aortic valve replacement (AVR) has emerged as an alternative to traditional AVR for patients with aortic stenosis who present a higher surgical risk, such as the elderly, or those with small or highly calcified aortic roots. With transcatheter aortic valve implantation - the other major AVR alternative - being used in increasingly lower-risk patients, the place of sutureless valves in the AVR landscape needs to be defined. In this review, we discuss recent data and expert opinion as it pertains to the subject of sutureless AVR.

RECENT FINDINGS

Several recent studies have evaluated the performance of sutureless valves in a variety of clinical contexts, including minimally invasive operations and high-risk surgical procedures. The optimal surgical technique for sutureless AVR has been refined through the publication of several reports addressing technical considerations. Reduction in operative times represents the main advantage of sutureless valves over conventional surgical prostheses, and the possibility of complete annular decalcification - and hence a reduced incidence of paravalvular leak - is the primary advantage over TAVI.

SUMMARY

Sutureless valves have emerged as an attractive option for high-risk patients or for complex surgeries where a minimization of bypass time is critical. However, there is limited data regarding long-term outcomes, durability or reoperation.

Ten-year experience with the Perceval S sutureless prosthesis: lessons learned and future perspectives

Aortic stenosis has traditionally been addressed with surgical aortic valve replacement (AVR). In recent years, several technologies have emerged as alternative treatment methods for aortic valve disease. Among them, the Perceval (LivaNova, London, UK) is a sutureless valve that has been used in clinical practice for over 10 years. It has been implanted in over 20,000 patients worldwide. With nearly 600 Perceval implants since 2011, the Montreal Heart Institute has developed a worldwide expertise with this technology. In this article, we provide an overview of the clinical data currently available in the literature and discuss the lessons we have learned from our experience with the Perceval prosthesis.

The Perceval Sutureless Aortic Valve: Review of Outcomes, Complications, and Future Direction

Surgical aortic valve replacement with a stented prosthesis has been the standard of care procedure for aortic stenosis. The Perceval (LivaNova, London, United Kingdom) is a sutureless aortic valve bioprosthesis currently implanted in more than 20,000 patients. The purpose of this article was to review the literature available after 9 years of clinical experience of the Perceval aortic valve. PubMED, Embase, and the Cochrane Library databases were searched. A meta-analysis of summary statistics from individual studies was conducted. A total of 333 studies were identified and 84 studies were included. Thirty-day mortality and 5-year survival ranged from 0% to 4.9% and 71.3% to 85.5%, respectively. Compared with stented prosthesis, pooled analysis demonstrated a statistically significant reduction in aortic cross-clamp and cardiopulmonary bypass times (minutes) with Perceval (38.6 vs 63.3 and 61.4 vs 84.9, P < 0.00001, respectively). Compared with transcatheter aortic valve implantation, pooled analysis demonstrated a statistically significant reduction with Perceval in paravalvular leakage (1.26% vs 14.31%) and early mortality (2.3% vs 6.9%). Favorable hemodynamics, acceptable valve durability, and ease of implantation in minimally invasive cases were reported as benefits. A trend toward increased rates of permanent pacemaker implantation and low postoperative platelet count were identified. Special use and off-label procedures described included bicuspid aortic valves, valve-in-valve for homograft and stentless prosthesis failure, concomitant valvular procedures, porcelain aorta, and endocarditis. The Perceval valve has shown safe clinical and hemodynamic outcomes. Outcomes support its continued usage and potential expansion.

Hemodynamic assessment of Perceval sutureless bioprosthesis by dobutamine stress echocardiography

OBJECTIVES

The aim of this study was to evaluate the hemodynamic performance of a sutureless bioprosthesis under high workload at mid-term follow-up.

METHODS

Thirty-two patients who underwent isolated aortic valve replacement with a Perceval sutureless bioprosthesis with a minimum follow-up of 1 year were enrolled in this study. S size prosthesis was deployed in 10 patients (31.3%), M size in 9 (28.1%), L size in 8 (25%) and XL size in 5 (15.6%). Effective orifice area (EOA), EOA index (EOAi), and transvalvular gradients were assessed at rest and during dobutamine stress echocardiography (DSE) a median of 19.5 months after surgery.

RESULTS

Dobutamine stress echocardiography (DSE) significantly increased heart rate, stroke volume, ejection fraction, and transvalvular gradients (peak gradient, 24.0 ± 7.6 vs 38.7 ± 13.6 mm Hg, P < .001; mean gradient, 12.6 ± 4.2 vs 19.8 ± 8.3, P < .001). When compared to baseline, estimated valve areas significantly increased at follow-up (EOA, 1.48 ± 0.46 vs 2.06 ± 0.67, P < .001; EOAi, 0.84 ± 0.26 vs 1.17 ± 0.37, P < .001). Mean percentage increase in EOAi was 40.3% ± 28.0%. S size prostheses had the highest increase in EOA1, but the difference was not significant (S 46.0% ± 27.5% vs M 45.4% ± 34.5% vs L 32.7% ± 26.4% vs XL 32.1% ± 20.5%, P = .66). Severe patient-prosthesis mismatch (EOAi ≤ 0.65 cm² /m² ) was present at rest in 8 patients (25%), but only in one patient (3.1%) during DSE.

CONCLUSIONS

The Perceval sutureless bioprosthesis demonstrated good hemodynamics at rest and under high workload. The significant increase in EOAi during DSE suggests the potential advantages of Perceval sutureless bioprostheses in case of small aortic annulus or when patient-prosthesis mismatch is anticipated.

Comparison of hemodynamic and clinical outcomes of transcatheter and sutureless aortic bioprostheses: how to make the right choice in intermediate risk patients

Current surgical treatment options for aortic valve stenosis (AS), as alternatives to that of conventional operation with a midline sternotomy, include sutureless valve replacement (SUAVR) and transcatheter valve implantation (TAVI). Patients with high surgical risk, or those who are judged to be inoperable, are typically good candidates for the TAVI procedure. The best treatment option in patients with an intermediate risk profile, however, the so called "grey zone", is still currently under debate. Sutureless aortic valve replacement has been recently presented as a valid alternative for patients with low- to intermediate-risk. Data available on prostheses' hemodynamic performance and patients' clinical outcomes play a crucial role in the process of device selection. Compared to TAVI, SUAVR provides lower rate of significant postoperative paravalvular leak (PVL), which has shown to be a predictor for mortality. On the contrary, transcatheter valves seem to perform better in terms of transvalvular mean and peak gradients. Therefore, SUAVR and TAVI are both reliable options in patients with severe aortic valve stenosis, as an alternative to conventional surgery, and the choice of the best device should be tailored to patient's anatomical and surgical characteristics.

Minimally invasive aortic valve replacement in high risk patient groups

Minimally invasive aortic valve replacement (AVR) aims to preserve the sternal integrity and improve postoperative outcomes. In low risk patients, this technique can be achieved with comparable mortality to the conventional approach and there is evidence of possible reduction in intensive care and hospital length of stay, transfusion requirement, renal dysfunction, improved respiratory function and increased patient satisfaction. In this review, we aim to asses if these benefits can be transferred to the high risk patient groups. We therefore, discuss the available evidence for the following high risk groups: elderly patients, re-operative surgery, poor lung function, pulmonary hypertension, obesity, concomitant procedures and high risk score cohorts.

Direct and adjusted indirect comparisons of perioperative mortality after sutureless or rapid-deployment aortic valve replacement versus transcatheter aortic valve implantation

OBJECTIVES

To determine which procedure, aortic valve replacement (AVR) with a sutureless or rapid-deployment prosthesis (SL-AVR) or transcatheter aortic valve implantation (TAVI), achieves better perioperative survival for severe aortic stenosis (AS), we conducted direct-comparison meta-analyses (DC-MAs) and an adjusted indirect-comparison meta-analysis (IDC-MA).

METHODS

We searched MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Trials through April 2016. Eligible studies were randomized controlled trials (RCTs) and propensity-score matched (PSM) studies. We performed a DC-MA-[A] of SL-AVR versus TAVI, a DC-MA-[B] of SL-AVR versus conventional AVR (C-AVR), and a DC-MA-[C] TAVI versus C-AVR. Then, we computed a IDC-MA-[A'] of TAVI versus SL-AVR from the results of the DC-MA-[B] and the DC-MA-[C].

RESULTS

We identified 6 RCTs and 30 PSM studies enrolling a total of 15,887 patients. The 3 DC-MAs demonstrated significantly lower perioperative (30-day or in-hospital) all-cause mortality after SL-AVR than after TAVI (odds ratio [OR], 0.48; 95% confidence interval [CI], 0.28 to 0.80; p=0.005) and no significant differences between SL-AVR and C-AVR (OR, 1.07; 95% CI, 0.60 to 1.94; p=0.81) and between TAVI and C-AVR (1.07; 95% CI, 0.90 to 1.27; p=0.45). The computed IDC-MA-[A'] indicated no significant difference in mortality between SL-AVR and TAVI (1.01; 95% CI, 0.54 to 1.86). Combining the results of the DC-MA-[A] and IDC-MA [A'] showed significantly lower mortality after SL-AVR than after TAVI (OR, 0.65; 95% CI, 0.44 to 0.97; p=0.03).

CONCLUSIONS

For patients with severe AS, SL-AVR may achieve better perioperative survival than TAVI.

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.

Valve-in-Valve Replacement Using a Sutureless Aortic Valve

BACKGROUND We present a unique case of a 61-year-old female patient with homograft deterioration after redo surgery for prosthetic valve endocarditis with root abscess. CASE REPORT The first operation was performed for type A dissection with root, arch, and elephant trunk replacement of the thoracic aorta. The present re-redo surgery was performed as valve-in-valve with a sutureless aortic bioprosthesis. The postoperative course was uneventful and the patient was discharged on day 6. CONCLUSIONS The current case report demonstrates that sutureless bioprostheses are an attractive option for surgical valve-in-valve procedures, which can reduce morbidity and mortality.

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.