Exploring the learning curve for minimally invasive sutureless aortic valve replacement

The Perceval Sutureless Bioprosthetic Aortic Valve: Evolution of Surgical Valve Technology

OBJECTIVE

The surgical treatment of aortic stenosis continues to evolve, and sutureless aortic valve replacement (SUAVR) is an emerging technology. With the Perceval S (Corcym, London, UK) as the only true sutureless valve on the market, the objective of this review is to analyze the current literature on Perceval S. Focusing on valve design and deployment as well as applications of the technology for challenging pathology, clinical outcomes are assessed, including a comparison with transcatheter AVR (TAVR).

METHODS

PubMed and MEDLINE were searched by 3 authors for studies analyzing SUAVR from inception to May 19, 2023.

RESULTS

SUAVR facilitates minimally invasive surgery and offers an alternative strategy for patients with small aortic annuli. It also has a time-saving advantage for patients who require complex operations. SUAVR results in excellent long-term morbidity, mortality, durability, and hemodynamic function. In comparison with conventional surgical AVR (SAVR), SUAVR does have a greater risk of postoperative pacemaker implantation; however, increasing user experience and refinements in implantation technique have contributed to reductions in this outcome. SUAVR results in morbidity and mortality that is similar to rapid-deployment AVR. Midterm outcomes are superior to TAVR; however, further robust investigation into all of these comparisons is ultimately necessary.

CONCLUSIONS

SUAVR bridges the gap in technology between SAVR and TAVR. The application of this exciting technology will undoubtedly grow in the coming years, during which additional investigation is paramount to optimize preoperative planning, valve deployment, and reintervention strategies.

Impact of practicing internal benchmarking on continuous improvement of cataract surgery outcomes: a retrospective observational study at Aravind Eye Hospitals, India

OBJECTIVE

We aim to assess the effectiveness of a cataract surgery outcome monitoring tool used for continuous quality improvement. The objectives are to study: (1) the quality parameters, (2) the monitoring process followed and (3) the impact on outcomes.

DESIGN AND PROCEDURES

In this retrospective observational study we evaluated a quality improvement (QI) method which has been practiced at the focal institution since 2012: internal benchmarking of cataract surgery outcomes (CATQA). We evaluated quality parameters, procedures followed and clinical outcomes. We created tables and line charts to examine trends in key outcomes.

SETTING

Aravind Eye Care System, India.

PARTICIPANTS

Phacoemulsification surgeries performed on 718 120 eyes at 10 centres (five tertiary and five secondary eye centres) from 2012 to 2020 were included.

INTERVENTIONS

An internal benchmarking of surgery outcome parameters, to assess variations among the hospitals and compare with the best hospital.

OUTCOME MEASURES

Intraoperative complications, unaided visual acuity (VA) at postoperative follow-up visit and residual postoperative refractive error (within ±0.5D).

RESULTS

Over the study period the intraoperative complication rate decreased from 1.2% to 0.6%, surgeries with uncorrected VA of 6/12 or better increased from 80.8% to 89.8%, and surgeries with postoperative refractive error within ±0.5D increased from 76.3% to 87.3%. Variability in outcome measures across hospitals declined. Additionally, benchmarking was associated with improvements in facilities, protocols and processes.

CONCLUSION

Internal benchmarking was found to be an effective QI method that enabled the practice of evidence-based management and allowed for harnessing the available information. Continuous improvement in clinical outcomes requires systematic and regular review of results, identifying gaps between hospitals, comparisons with the best hospital and implementing lessons learnt from peers.

Propensity matched analysis of minimally invasive versus conventional isolated aortic valve replacement

OBJECTIVE

To analyse the early and mid-term outcome of patients undergoing conventional aortic valve replacement (AVR) versus minimally invasive via hemi-sternotomy aortic valve replacement (MIAVR).

METHODS

A single centre retrospective study involving 653 patients who underwent isolated aortic valve replacement (AVR) either via conventional AVR (n = 516) or MIAVR (n = 137) between August 2015 and March 2020. Using pre-operative characteristics, patients were propensity matched (PM) to produce 114 matched pairs. Assessment of peri-operative outcomes, early and mid-term survival and echocardiographic parameters was performed.

RESULTS

The mean age of the PM conventional AVR group was 71.5 (±8.9) years and the number of male (n = 57) and female (n = 57) patients were equal. PM MIAVR group mean age was 71.1 (±9.5) years, and 47% of patients were female (n = 54) and 53% male (n = 60). Median follow-up for PM conventional AVR and MIAVR patients was 3.4 years (minimum 0, maximum 4.8 years) and 3.4 years (minimum 0, maximum 4.8 years), respectively. Larger sized aortic valve prostheses were inserted in the MIAVR group (median 23, IQR = 4) versus conventional AVR group (median 21, IQR = 2; p = 0.02, SMD = 0.34). Cardiopulmonary bypass (CPB) time was longer with MIAVR (94.4 ± 19.5 minutes) compared to conventional AVR (83.1 ± 33.3; p = 0.0001, SMD = 0.41). Aortic cross-clamp (AoX) time was also longer in MIAVR (71.6 ± 16.5 minutes) compared to conventional AVR (65.0 ± 52.8; p = 0.0001, SMD = 0.17). There were no differences in the early post-operative complications and mortality between the two groups. Follow-up echocardiographic data showed significant difference in mean aortic valve gradients between conventional AVR and MIAVR groups (17.3 ± 8.2 mmHg vs 13.0 ± 5.1 mmHg, respectively; p = 0.01, SMD = -0.65). There was no significant difference between conventional AVR and MIAVR in mid-term survival at 3 years (88.6% vs 92.1%; log-rank test p = 0.31).

CONCLUSION

Despite the longer CPB and AoX times in the MIAVR group, there was no significant difference in early complications, mortality and mid-term survival between MIAVR and conventional AVR.

Consensus statement on aortic valve replacement via an anterior right minithoracotomy in the UK healthcare setting

The wide uptake of anterior right thoracotomy (ART) as an approach for aortic valve replacement (AVR) has been limited despite initial reports of its use in 1993. Compared with median sternotomy, and even ministernotomy, ART is considered to be less traumatic to the chest wall and to help facilitate quicker patient recovery. In this statement, a consensus agreement is outlined that describes the potential benefits of the ART AVR. The technical considerations that require specific attention are described and the initiation of an ART programme at a UK centre is recommended through simulation and/or use of specialist instruments in conventional cases. The use of soft tissue retractors, peripheral cannulation, modified aortic clamping and the use of intraoperative adjuncts, such as sutureless valves and/or automated knot fasteners, are important to consider in order to circumvent the challenges of minimal the altered exposure via an ART.A coordinated team-based approach that encourages ownership of the programme by team members is critical. A designated proctor/mentor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases are important steps to consider.

Rapid-Deployment Aortic Valve Replacement: Patient Selection and Special Considerations

Sutureless or rapid deployment valves in the setting of aortic valve replacement (AVR) is an emerging surgical technique using the transcatheter valve technology, which may lead to reduction in cross-clamp time and potentially better hemodynamics compared to a stented bioprosthetic valve. The absence of subannular pledgets results to excellent hemodynamic performance with reduced turbulent flow and larger effective orifice area. However, complications from both surgical and transcatheter AVR may still occur and impact survival. The incidence of paravalvular leakage and permanent pacemaker implantation are not low. Although technical modifications can improve these outcomes, there is a learning curve effect. Therefore, technical and anatomical considerations as well as better patient selection are paramount for better outcomes. In this review, we discuss the use of sutureless or rapid deployment valves in setting of (1) complex procedures, (2) minimally invasive AVR, and (3) small aortic annulus. The advantage of sutureless or rapid deployment valves in terms of mortality remains to be clarified; therefore, it is necessary to accumulate long-term outcomes in an appropriate patient cohort.

Pearls, pitfalls, and surgical indications of the Intuity TM heart valve: A rapid deployment bioprosthesis. A systematic review of the literature

OBJECTIVES

To highlight short- and long-term clinical outcomes of the Intuity TM rapid deployment prosthesis for surgical aortic valve replacement.

METHODS

We reviewed on PubMed/MEDLINE, Embase, SciELO, LILACS, CCTR/CENTRAL, and Google Scholar for clinical trials, retrospective clinical studies, meta-analysis, and gray literature.

RESULTS

Fourty-five clinical studies with 12.714 patients were included in the analysis. Thirty-day mortality ranged from 3.8% for Intuity and 3.9% for transcatheter aortic valve replacement (TAVR). The incidence of paravalvular leak (PVL) (Intuity 0% and TAVR 2.17%), permanent pacemaker implantation (Intuity 11.11% and TAVR 12.5%), stroke (Intuity 2.2% and TAVR 2.6%), myocardial infarction (MI) (Intuity 0% and TAVR 1%), were all higher in the TAVR group. Compared to other sutured bioprosthesis (SB), mortality ranged from 0% to 3.9% for Intuity and 0%-6.9% for SB. Long-term cardiac mortality ranged from 0.9% to 1.55% for Intuity and 1.4%-3.3% for the Perceval valve. The incidence of PVL (Intuity 0.24%-0.7% and Perceval 0%-1%), endocarditis (Intuity 0.2%-0.7% and Perceval 1.6%-6.6%), stroke (Intuity 0.36%-1.4% and Perceval 0%-0.8%), MI (Intuity 0.07%-0.26%), and SVD (Intuity 0.12%-0.7% and Perceval 0%) were comparable. Compared to standard full sternotomy (SFS), minimally invasive surgery (MINV) mortality ranged from 0% to 4.3% for MINV and 0%-2.1% for SFS. Hospital costs outcomes ranged from $37,187-$44,368 for the Intuity, $69,389 for TAVR, and $13,543 for SB. Intuity short-term mortality ranged between 0.9% and 12.4% while long-term mortality ranged between 2.6% and 20%.

CONCLUSIONS

This manuscript provides a 360° overview of the current rapid deployments, sutureless, and TAVR prosthesis.

Understanding aortic valve repair through Ozaki procedure: A review of literature evidence

BACKGROUND

Aortic valve neocuspidization (AV Neo) using glutaraldehyde-treated autologous pericardium was first reported by Ozaki et al. in 2007. This technique has become an alternative to tissue and mechanical valve in selected patients as long-term anticoagulation is not required and shows promising midterm results and durability.

METHOD

A comprehensive search was performed on the major database using the search terms "Ozaki technique" AND "Aortic Valve Neocuspidization" AND "AV Neocuspidization" AND "Autologous pericardium" AND "glutaraldehyde-treated autologous pericardium." Articles up to August 1st, 2021 were included in this study.

RESULTS

A total of nine studies with a total of 1342 patients were included. The mean age was 67.36 and 54.23% were male. 66.32% and 23.92% of patients had aortic stenosis and aortic regurgitation, respectively. 66% of patients had a native tricuspid aortic valve (AV) and 31.37% of patients' native AV was bicuspid. Three studies reported their experience performing AV Neo via ministernotomy.

CONCLUSION

AV Neo can be a suitable alternative to surgical AV replacement in selected patients. The short- and midterm outcomes are comparable without the need for long-term oral anticoagulation. Long-term follow-up data are required for this novel approach to be widely adopted.

Eligibility for minithoracotomy aortic valve replacement: from Van Praet classification to complex scanner measurements

Van Praet proposed a classification to predict the ease of minithoracotomy aortic valve replacement (MT-AVR) based on the position of the aorta in the thorax. We have evaluated the relevance of complex computed tomography (CT) scan measurements to predict the ease of performing a MT-AVR. The first 57 patients who underwent MT-AVR from February 2018 to June 2020 were selected prior to surgery using Van Praet's IA and IB classes. We made additional measurements on aorta position related to the chest and the incision on the preoperative CT scan. The main objective was to correlate complex CT measurements with different operating durations. Van Praet criteria were significantly related to the distance from the center of the aorta to the midline (p value < 0.001), the distance from the center of the aortic ring to the midline (p value = 0.013) and aorto-sternal angle (p < 0.001). We did not find a correlation between CT criteria and the different surgical steps durations in patients belonging to Van Praet classes IA and IB. Our cohort of Van Praet class Ia and Ib patients were able to benefit from a MT-AVR without the need for conversion. Complex CT measurements do not provide additional information to predict surgical difficulties. This classification appears to be sufficient to determine a patient's eligibility for MT-AVR, even for a surgeon experienced in sternotomy in his first MT-AVR.

Facilitating Peer Interaction Regulation in Online Settings: The Role of Social Presence, Social Space and Sociability

A plethora of studies stress students' self-regulated learning (SRL) skills to be conditional for successful learning in school and beyond. In general, self-regulated learners are actively engaged in constructing their own understanding also including the regulation of contextual features in the environment. Within the contextual features, the regulation of peer interaction is necessary, because college courses increasingly require peer learning. This goes along with the increasing interest for online learning settings, due in no small part to the recent COVID-19 pandemic. In the present study we explore how social presence (i.e., the degree to which the other person is perceived as physical "real"), social space (i.e., trust building between peers) and sociability (i.e., the degree to which the virtual learning environment supports social presence and social space) are essential elements in the regulation of online peer interaction. To shed light in this matter, higher education students were qualitatively followed for 1 year in an online academic writing course by using retrospective interviews (n = 7) and reflective questions (n = 62). Additionally, for social presence, students' perceptions were quantitatively measured with a validated questionnaire (n = 41). The results show that the planning phase is the most important phase for supporting students' social presence because that is where the regulation of peer interaction becomes important. The sociability has an important role here as well becoming less prominent further on in the self-regulation process. In the SRL follow-up phases, students look for other ways to increase their social presence and social space in order to shape the regulation of peer interaction from a position of trust. In the evaluation phase, students are aware of the importance of social presence but less of social space for the regulation of peer interaction. We conclude with some design principles to facilitate students' regulation of peer interaction in online settings.

Benefits and Pitfalls of the Perceval Sutureless Bioprosthesis

Objective: To highlight the main target points covered by clinical studies on the Perceval sutureless valve for surgical aortic valve replacement (SAVR) and raise a point of discussion for further expansion of its use when compared with stented bioprostheses (SB) and transcatheter aortic valve replacement (TAVR).

Methods: We reviewed clinical trials and retrospective studies published up to date and compared the outcomes in terms of mortality, myocardial infarction (MI) stroke, paravalvular leak (PVL), permanent pacemaker implantation (PPI), bleeding and long-term outcomes.

Results: Clinical studies showed that 30-day mortality ranged from 0–4% for Perceval and 2.9–7% for TAVR. The incidence of PVL (Perceval 1.9–19.4 vs. TAVR 9–53.5%), PPI (Perceval 2–11.2 vs. TAVR 4.9–25.5%), stroke (Perceval 0 vs. TAVR 0–2.8%), MI (Perceval 0 vs. TAVR 0–3.5%), were all higher in the TAVR group. Compared to other SB, mortality ranged from 0–6.4% for Perceval and 0–5.9% for SB. The incidence of PVR (Perceval 1–19.4 vs. SB 0–1%), PPI (Perceval 2–10.7 vs. SB 1.8–8.5%), stroke (Perceval 0–3.7 vs. SB 1.8–7.3%) and MI (Perceval 0–7.8 vs. SB 0–4.3%) were comparable among the groups. In patients with a bicuspid aortic valve, mortality rate was (0–4%) and PVL incidence was (0–2.3%). However, there was a high incidence of PPI (0–20%), and stroke (0–8%). Long-term survival ranged between 96.7–98.6%.

Conclusions: The Perceval bioprosthesis has proved to be a reliable prosthesis for surgical aortic valve replacement due to its implantation speed, the reduced cardiopulmonary bypass time, the reduced aortic cross-clamp time and the shorter intensive care unit and hospital length of stay.

Converging rapid deployment prostheses with minimal access surgery: analysis of early outcomes

Background

Sutureless prostheses may have added benefit when combined with minimal access surgery, although this has not been fully assessed in the literature. This study aims to provide a comparative analysis of the Perceval valve comparing median sternotomy (MS) with mini-sternotomy (MIS).

Methods

A retrospective analysis of prospectively collected data was conducted for all isolated aortic valve replacement (AVR), using the Perceval valve, for severe aortic stenosis cases in the period 2014 to 2019. Patients undergoing concomitant valve or revascularisation surgery were excluded.

Results

A total of 78 patients were included: MS group 41; MIS group 37. Operatively, bypass times were comparable between MS and MIS groups (mean 89.3 vs 83.4, p = 0.307), as were aortic cross clamp times (58.4 vs 55.9, p = 0.434). There were no operative deaths or new onset post-operative neurology. MIS was a predictor of reduced stay in the intensive care unit (coef − 3.25, 95% CI [− 4.93, − 0.59], p = 0.036) and hospital stay overall (p = 0.004). Blood transfusion units were comparable as were the incidence of heart block (n = 5 vs n = 3, p = 0.429) and new onset atrial fibrillation (n = 15 vs n = 9, p = 0.250). Follow-up echocardiography found a significant improvement in effective orifice area, left ventricular dimension and volume indices, and LVEF (p > 0.05) for all patients. Multivariate analysis found mini-sternotomy to be a predictor for reduced LV diastolic volume (coef − 0.35, 95% CI [− 1.02, − 0.05], p = 0.05).

Conclusions

The combination of minimal access surgery and sutureless AVR may enhance patient recovery and provide early LV remodelling.

BISMICS consensus statement: implementing a safe minimally invasive mitral programme in the UK healthcare setting

Disseminating the practice of minimally invasive mitral surgery (mini-MVS) can be challenging, despite its original case reports a few decades ago. The penetration of this technology into clinical practice has been limited to centres of excellence, and mitral surgery in most general cardiothoracic centres remains to be conducted via sternotomy access as a first line. The process for the uptake of mini-MVS requires clearer guidance and standardisation for the processes involved in its implementation. In this statement, a consensus agreement is outlined that describes the benefits of mini-MVS, including reduced postoperative bleeding, reduced wound infection, enhanced recovery and patient satisfaction. Technical considerations require specific attention and can be introduced through simulation and/or use in conventional cases. Either endoballoon or aortic cross clamping is recommended, as well as femoral or central aortic cannulation, with the use of appropriate adjuncts and instruments. A coordinated team-based approach that encourages ownership of the programme by the team members is critical. A designated proctor is also recommended. The organisation of structured training and simulation, as well as planning the initial cases, is an important step to consider. The importance of pre-empting complications and dealing with adverse events is described, including re-exploration, conversion to sternotomy, unilateral pulmonary oedema and phrenic nerve injury. Accounting for both institutional and team considerations can effectively facilitate the introduction of a mini-MVS service. This involves simulation, team-based training, visits to specialist centres and involvement of a designated proctor to oversee the initial cases.

Is it safe to move away from a full sternotomy for aortic valve replacement?

BACKGROUND

Minimally invasive surgical approaches have gained popularity among patients and surgeons. The aim of this project was to assess the safety of initiating aortic valve replacement via an anterior right thoracotomy program.

METHODS

Between May 2015 and May 2019, data of all isolated primary aortic valve replacements were extracted retrospectively from our prospectively collected database and categorized into conventional median sternotomy, hemisternotomy, and anterior right thoracotomy cases. In total, 661 patients underwent isolated primary aortic valve replacement, of whom 429 (65%) had a median sternotomy, 126 (19%) had a hemisternotomy, and 106 (16%) had an anterior right thoracotomy. Preoperative characteristics were similar in each of the three groups. Statistical testing of the surgical groups was undertaken using the chi-square test for categorical variables and one-way analysis of variance with Tukey post-hoc pairwise tests (where appropriate) for continuous variables, to identify differences between pairs of data.

RESULTS

Cardiopulmonary bypass and crossclamp times were significantly longer in the anterior right thoracotomy group compared to the hemisternotomy and median sternotomy groups (p < 0.001). Blood loss was significantly less and hospital stay significantly shorter in the hemisternotomy group compared to median sternotomy group but not the anterior right thoracotomy group. Mortality, stroke, renal, gastrointestinal and respiratory complications showed no statistical differences.

CONCLUSION

Surgical aortic valve replacement had a very low mortality and morbidity in our experience, and it is safe to start a minimal access program for aortic valve replacement.

Minimally invasive surgical aortic valve replacement: The RALT approach

Less-invasive techniques for cardiothoracic surgical procedures are designed to limit surgical trauma, but the technical requirements and preoperative planning are more demanding than those for conventional sternotomy. Patient selection, interdisciplinary collaboration, and surgical skills are key factors for procedural success. Aortic valve replacement is frequently performed through an upper hemisternotomy, but the right anterior minithoracotomy represents an even less traumatic, technical advancement. Preoperative assessment of the ascending aorta in relation to the sternum is mandatory to select patients and the intercostal access site. This description of the surgical technique focuses on the specific procedural details including the obligatory planning with computed tomography and our cannulation strategy. We also sought to define the anatomical ascending aorta-sternal relationship, as it is of utmost importance in preoperative computed tomographic planning.

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.

Simulation of a Right Anterior Thoracotomy Access for Aortic Valve Replacement Using a 3D Printed Model

OBJECTIVE

The right anterior lateral thoracotomy (RALT) approach for aortic valve replacement provides excellent outcomes in expert hands while avoiding sternal disruption. It, however, remains a technically demanding niche operation. Instrument trajectories via this access are influenced by patient anatomy, the intercostal space chosen, and surgical retraction maneuvers.

METHODS

To simulate the typical surgical maneuvers, on an anatomically accurate model, and to measure the instrument trajectories, we generated a 3-dimensional (3D) printed model of the heart and chest cavity. A simulated approach to the base of the right coronary sinus via the medial-second intercostal, the lateral-second intercostal, or third intercostal space was made. Keeping the instrument in place, 3D scans of the models and geometrical measurements of the instrument trajectories were performed.

RESULTS

The 3D scans of the 3D printed model showed a high fidelity when compared to the original computed tomographic scan image geometry (mean deviation of 1.26 ± 1.27mm). The instrument intrathoracic distance was 75 mm via the medial-second, 115 mm via the lateral-second, and 80 mm via the third intercostal space. The 3D angulation of the instrument to the incision was 33.77^o, 55.93^o, and 38.4^o respectively. The distance of the instrument to the lateral margin was 12, 26, and 5 mm respectively. The cranial margin of the incision was always a limiting margin for the instrument.

CONCLUSIONS

Three-dimensional printing and 3D scanning facilitated a realistic simulation of the instrument trajectory during RALT approach. The lateral-second intercostal approach showed the most favorable approach angle and distance from the lateral margin, although it also had the longest intrathoracic distance.

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.