Sutureless Bioprostheses for Aortic Valve Replacement: An Updated Systematic Review with Long-Term Results

Background: In recent years, in case of aortic valve replacement (AVR), a significant increase in the use of bioprostheses has been observed. The Perceval sutureless bioprosthesis has proven to be safe and reliable in the short and mid-term, with limited but promising long-term results. An updated systematic review with the long-term results of patients who underwent a sutureless bioprosthesis implantation with a Perceval biological valve is herewith presented. Methods: Studies published between 2015 and 2024, including the long-term outcomes-with clinical as well as echocardiographic information for up to five years-of patients who underwent a Perceval implantation for AVR were selected from the published literature. The Cochrane GRADE system was used to assess the study quality, and the risk of bias in non-randomized studies (ROBINS-I) tool was used to evaluate studies. Results: Ten studies were selected with an overall number of 5221 patients. The long-term survival ranged from 64.8 to 87.9%, freedom from structural valve degeneration (SVD) from 96.1 to 100%, freedom from significant paravalvular leak from 98.5 to 100%, freedom from prosthetic endocarditis from 90.7 to 99%, and freedom from reintervention from 94 to 100%. The long-term mortality ranged from 6.5 to 27.4%. SVD was observed in 0-4.8% patients. Significant paravalvular leak was observed in 0-3.4% patients, and infective endocarditis was observed in 0-3.4%. A bioprosthesis-related reintervention at long-term follow-up was required for 0-4.3% of patients, and 1.7-7.1% of patients required a late new pacemaker implantation. The transprosthetic mean pressure gradient ranged from 9 to 14.7 mmHg, peak pressure gradient ranged from 17.8 to 26.5 mmHg, and EOA ranged from 1.5 to 1.7 cm2. Conclusions: This systematic review shows that there is still a paucity of data about sutureless bioprostheses. Nevertheless, the clinical results from prospective studies or retrospective series are encouraging. Medium- and long-term results seem to support the increasing use of this type of prosthesis.

Differences between valve types in anatomic changes of the aortic root after surgical aortic valve replacement

Background

When transcatheter aortic valve-in-surgical aortic valve (TAV-in-SAV) is considered as a secondary interventional option, it is desirable to estimate the risk of coronary obstruction during future TAV-in-SAV before the initial surgical aortic valve replacement (SAVR), for which knowledge of the anatomic changes after SAVR is essential. We investigated the changes in the aortic root and evaluated the differences in changes between valve types.

Methods

Pre- and post-SAVR computed tomography scans of 124 patients with aortic stenosis who underwent SAVR with various bioprosthetic valves were analyzed retrospectively. Postoperative aortic root changes and parameters related to future TAV-in-SAV were compared between the sutured valve group and rapid-deployment/sutureless valve group.

Results

After SAVR, the coronary height in the sutured valve group and rapid-deployment/sutureless valve group was shortened by a median of 4.6 to 5.3 mm and 0.5 to 2.2 mm, respectively, and the sinus of Valsalva (SOV) diameter was reduced by a median of 1.6 to 2.7 mm and 0.1 to 1.3 mm, respectively. A significantly higher proportion of patients in the rapid deployment/sutureless valve group had a coronary orifice (especially in the right coronary artery) above the risk plane. The valve-to-coronary distance and valve-to-aorta distance (VTA) were adequate in most patients. The only difference between the groups was in the left VTA.

Conclusions

Decreases in coronary height and SOV diameter were observed after SAVR, especially in the sutured valve group. The aortic root structure was better preserved in the rapid-deployment/sutureless valve group. This may be advantageous for future TAV-in-SAV. These results are important for considering the feasibility of future TAV-in-SAV.

Does valve size impact hemodynamic, left ventricular mass regression, and prosthetic valve deterioration with a sutureless aortic valve?

OBJECTIVE

To assess the mid-term clinical outcomes, hemodynamics, left ventricular (LV) mass regression, and structural valve deterioration (SVD) in patients implanted with the Perceval aortic sutureless valve across valve sizes.

METHODS

Data were obtained from a multicenter European trial and a US Investigational Device Exemption trial. Echocardiography data were analyzed by an echocardiography core lab. A mixed-effects regression model was used to assess relationships between hemodynamic outcomes, time from the procedure, and valve sizes. The Valve Academic Research Consortium (VARC)-3 definition for bioprosthetic valve failure was applied.

RESULTS

A Perceval sutureless valve was implanted in 970 patients. The median patient age was 77.8 years, 57.2% were female, the median Society of Thoracic Surgeons predicated risk of mortality was 3.3% (range, 2.1%-6.2%), and 33.4% had a concomitant procedure. The median clinical follow-up was 45.7 months (range, 28.2-76.1 months). Small and medium valves were implanted more commonly in women than in men (16.9% vs 1.9% for small and 55.1% vs 19.5% for medium; P < .001). The mean aortic valve gradients decreased significantly postimplantation and remained stable across all valve sizes throughout the follow-up period. All patients were free from severe patient-prosthesis mismatch (with an effective orifice area/m2 of >0.8). Significant LV mass regression was documented regardless valve sizes, plateaued at -9.1% at 5 years. Freedom from SVD and reintervention were 95.2% and 96.3%, respectively, at 5 years and were independent of implanted valve size (P = .22). The VARC-3 stage 3 bioprosthetic valve failure rate was low, 2.8% at 5 years.

CONCLUSIONS

The Perceval valve demonstrated low and stable mean gradients, significant LV mass regression, and low SVD and reintervention rates across all valve sizes.

Single-center real-world data and technical considerations from 100 consecutive patients treated with the Perceval aortic bioprosthesis

Objectives

Although the Perceval sutureless aortic valve bioprosthesis presents a feasible alternative to conventional aortic valve prostheses, the extent of its applicability with respect to technical considerations for a real-world patient collective is still under debate.

Methods

One hundred patients received the Perceval prosthesis [males: 59; age: 72.5 (7.3-79) years] between December 2015 and February 2023 [EuroSCORE II: 2.8 (1.7-5.4)] for an aortic valve replacement (AVR), with additional concomitant procedures, for underlying severe aortic valve stenosis [n = 93 (93)], endocarditis [n = 5 (5)], and redo AVR [n = 7 (7)] including a prior surgical AVR [n = 4 (4)] and a failed transcatheter aortic valve implantation [n = 3 (3)]. Surgery was conducted primarily by median sternotomy [n = 71 (71)] and, alternatively, by the upper hemisternotomy approach [n = 29 (29)].

Results

Over a median follow-up time of 36.5 (16.5-53) months, eight patients (8%) underwent postoperative pacemaker implantation, with five (5%) due to high-grade atrioventricular block, while nine patients experienced a stroke (9%). The median values of maximum and mean gradients across all valve sizes were 22 (18-27.5) mmHg and 10 (13-18) mmHg, respectively. Two patients (2%) had moderate and one (1%) had severe paravalvular leakage, with the latter presenting the only case of underlying valve migration and induced redo AVR with valve explantation 2 days following initial surgery. Thirty-day mortality (and overall mortality) was 5% and 26%, respectively.

Conclusion

The implantation of the Perceval bioprosthesis is feasible for a variety of indications, with excellent hemodynamic results and low complication rates in a real-world high-risk patient collective.

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.

Transcatheter Aortic Valve Replacement in Degenerated Perceval Bioprosthesis: Clinical and Technical Aspects in 32 Cases

BACKGROUND

Sutureless aortic bioprostheses are increasingly being used to provide shorter cross-clamp time and facilitate minimally invasive aortic valve replacement. As the use of sutureless valves has increased over the past decade, we begin to encounter their degeneration. We describe clinical outcomes and technical aspects in patients with degenerated sutureless Perceval (CorCym, Italy) aortic bioprosthesis treated with valve-in-valve transcatheter aortic valve replacement (VIV-TAVR).

METHODS

Between March 2011 and March 2023, 1310 patients underwent aortic valve replacement (AVR) with Perceval bioprosthesis implantation. Severe bioprosthesis degeneration treated with VIV-TAVR occurred in 32 patients with a mean of 6.4 ± 1.9 years (range: 2-10 years) after first implantation. Mean EuroSCORE II was 9.5 ± 6.4% (range: 1.9-35.1%).

RESULTS

Thirty of thirty-two (94%) VIV-TAVR were performed via transfemoral and two (6%) via transapical approach. Vascular complications occurred in two patients (6%), and mean hospital stay was 4.6 ± 2.4 days. At mean follow-up of 16.7 ± 15.2 months (range: 1-50 months), survival was 100%, and mean transvalvular pressure gradient was 18.7 ± 5.3 mmHg.

CONCLUSION

VIV-TAVR is a useful option for degenerated Perceval and appears safe and effective. This procedure is associated with good clinical results and excellent hemodynamic performance in our largest single-center experience.

The Sutureless Biological Bentall Procedure: A New Technique to Create a Modular Valve-Conduit Construct

The Perceval sutureless valve (Corcym, Saluggia, Italy) has been effectively adopted by surgeons for the treatment of degenerative aortic valve stenosis. Its simplified true sutureless implantation technique has proven useful for minimally invasive cases, but the use of Perceval as part of more complex root replacement has not previously been described. We present a novel technical modification to the manufactured biologic Bentall, called the sutureless biological Bentall. This technique allows for a true modular valve-conduit construction that will simplify future reintervention.

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.

Two-year outcomes after transcatheter aortic valve-in-valve implantation in degenerated surgical valves

BACKGROUND

Transcatheter aortic valve-in-valve implantation (ViV-TAVI) has emerged in recent years as a safe alternative to redo surgery in high-risk patients. Although early results are encouraging, data beyond short-term outcomes are lacking. Herein, we aimed to assess the 2-year outcomes after ViV-TAVI.

METHODS

Patients undergoing ViV-TAVI for degenerated surgical valves between 2013 and 2019 at the Cleveland Clinic were reviewed. The coprimary endpoints were all-cause mortality and congestive heart failure (CHF) hospitalizations. We used time-to-event analyses to assess the primary outcomes. Further, we measured the changes in transvalvular gradients and the incidence of structural valve deterioration (SVD).

RESULTS

One hundred and eighty-eight patients were studied (mean age = 76 years; 65% males). At 2 years of follow-up, all-cause mortality and CHF hospitalizations occurred in 15 (8%) and 28 (14.9%) patients, respectively. On multivariable analysis, the postprocedural length of stay was a significant predictor for both all-cause mortality (hazard ratio [HR] = 1.1; 95% confidence interval [CI]: 1.01, 1.19) and CHF hospitalization (HR = 1.16; 95% CI: 1.07, 1.27). However, the internal diameter of the surgical valve was not associated with significant differences in both primary endpoints. For hemodynamic outcomes, nine patients (4.8%) developed SVD. The mean and peak transvalvular pressure gradients remained stable over the follow-up period.

CONCLUSION

ViV-TAVI for degenerated surgical valves was associated with favorable 2-year clinical and hemodynamic outcomes. Further studies are needed to better understand the role of ViV-TAVI as a treatment option in the life management of aortic valve disease.

Predictors of Procedural Success in Patients With Degenerated Surgical Valves Undergoing Transcatheter Aortic Valve-in-Valve Implantation

Background: Valve-in-Valve transcatheter aortic valve implantation (ViV-TAVI) is a growing alternative for redo-surgery in patients with degenerated surgical valves. To our knowledge, data are lacking on the determinants on ViV-TAVI procedural success in patients with degenerated surgical valves.

Methods: All consecutive patients undergoing ViV-TAVI for degenerated surgical valves at the Cleveland Clinic were analyzed. Data were extracted from our patient registry on baseline patient characteristics, echocardiographic parameters, and procedural details. To identify possible predictors of ViV-TAVI procedural success, we employed a multivariate logistic regression model.

Results: A total of 186 patients who underwent ViV-TAVI were analyzed, with procedural success (VARC-2 device success and absence of periprocedural MACCE) reported in 165 (88.7%) patients. Patients with successful ViV-TAVI were significantly younger and had more frequent utilization of the transfemoral access than those with failed procedure. Other baseline and procedural characteristics were comparable between both groups. In terms of echocardiographic parameters, the procedural success group had a significantly lower AV peak pressure gradient (62.1 ± 24.7 vs. 74.1 ± 34.6 mmHg; p = 0.04) and lower incidence of moderate-to-severe aortic regurgitation [AR] (30.4 vs. 55%; p = 0.04). However, no significant differences between both groups were noted in terms of AV mean pressure gradient and left ventricular measurements. In multivariate analysis, lower AV peak pressure gradient (OR = 0.97, 95% CI: 0.95–0.99) and absence of moderate-to-severe AR (OR = 0.65, 95% CI: 0.44–0.95) at baseline emerged as independent predictors of ViV-TAVI procedural success.

Conclusion: Valve-in-Valve TAVI for degenerated surgical valves is a feasible approach with high success rates, especially in those with lower AV peak pressure gradient and absence of moderate-to-severe AR. Studies with larger sample size and longer follow-up are required to further characterize the predictors of ViV-TAVI success and other clinical outcomes.

Sutureless versus rapid deployment aortic valve replacement: results from a multicentric registry

BACKGROUND

To compare clinical and hemodynamic in-hospital outcomes of patients undergoing sutureless versus rapid deployment aortic valve replacement (SURD-AVR) in the large population of the Sutureless and Rapid Deployment International Registry (SURD-IR).

METHODS

We examined 4695 patients who underwent isolated or combined SURD-AVR. The "sutureless" Perceval valve was used in 3133 patients and the "rapid deployment" Intuity in 1562. Potential confounding factors were addressed by the use of propensity score matching. After matching, 2 well-balanced cohorts of 823 pairs (isolated SURD-AVR) and 467 pairs (combined SURD-AVR) were created.

RESULTS

Patients who received Perceval and Intuity valves showed similar in-hospital mortality and rate of major postoperative complications. Perceval was associated shorter cross clamp and cardiopulmonary bypass time. In the isolated SURD-AVR group, patients receiving Perceval were more likely to undergo anterior right thoracotomy incision. Postoperative transvalvular gradients were significantly lower for the Intuity valve compared to those of the Perceval valve, either in isolated and combined SURD-AVR. The Intuity valve was associated with a lower rate of postoperative mild aortic regurgitation.

CONCLUSIONS

Our results confirm the safety and efficacy of SURD-AVR regardless of the valve type. The Perceval valve was associated with reduced operative times and increased anterior right thoracotomy incision. The Intuity valve showed superior hemodynamic outcomes and a lower incidence of postoperative mild aortic regurgitation.

Valve-in-valve transcatheter aortic valve implantation for the failing surgical Perceval bioprosthesis

INTRODUCTION

The Perceval Valve has been increasingly used in Surgical Aortic Valve Replacement (SAVR) recently due to ease of implantation. However, we have seen some cases of relatively early haemodynamic failure of the Perceval valve and these patients may then present for valve-in-valve transcatheter aortic valve implantation (ViV-TAVI). Experience of ViV-TAVI in the Perceval valve is limited.

METHODS

We report our experience of VIV-TAVI in four cases of early-failing Perceval valves, two with stenosis and two with regurgitation. We also review the literature with regard to ViV-TAVI for this indication.

RESULTS

Four patients aged between 66 and 78 years presented with Perceval valve dysfunction an average of 4.6 years following SAVR. All cases underwent Heart Team discussion and a ViV-TAVI procedure was planned thereafter. Strategies to ensure crossing through the centre of the valve and not outside any portion of the frame were found to be essential. Three patients had self-expanding valves implanted and one had a balloon-expandable prosthesis. The average aortic valve area (AVA) improved from 0.8 cm² pre-procedure to 1.5 cm² post-procedure*. The mean gradient (MG) improved from 35.5 mmHg (range 19.7-53 mmHg) pre-procedure to 14.8 mmHg (range 7-30 mmHg) post-procedure. In one patient a MG of 30 mmHg persisted following valve deployment. There were no significant peri-procedural complications.

CONCLUSIONS

ViV-TAVI is a useful option for failed Perceval prostheses and appears safe and effective in this small series. Crossing inside the whole frame of the Perceval valve is essential.

Effect of conventional and rapid-deployment aortic valve replacement on the distance from the aortic annulus to coronary arteries

OBJECTIVES

This study aimed to compare the effect of surgical aortic valve replacement (SAVR) on coronary height in patients undergoing SAVR with rapid-deployment or SAVR with several standard sutured bioprostheses. This study may identify patients at higher risk of coronary obstruction during valve-in-valve procedures.

METHODS

We analysed 112 patients [mean age 71 (9 SD) years] who underwent SAVR with either a rapid-deployment aortic bioprosthesis (EDWARDS INTUITY Elite Valve) or other standard sutured biological valves. The coronary heights were assessed by computed tomography scan with the Philips 3D HeartNavigator system.

RESULTS

Two groups of patients were analysed: 51 (45.5%) patients implanted with an RD-AVR, which is a supra-annular valve that requires 3 anchoring sutures without the use of pledgets, and 61 (54.5%) patients implanted with a conventional supra-annular sutured bioprosthesis. The mean right and left coronary artery-to-annulus (RCAA and LCAA) heights at baseline were 16.9 (4.6 SD) and 14.2 (4.0 SD) mm in the standard sutured group and 16.3 (3.5 SD) and 12.8 (2.9 SD) mm in the RD-AVR group, respectively; a significantly shorter distance was observed for the left coronary artery in the rapid-deployment group (P = 0.420 for RCAA height and P = 0.044 for LCAA). Postoperatively, the mean RCAA and LCAA heights were significantly decreased in both groups compared to baseline. A mean of 11.5 (4.8 SD) mm for the RCAA and 7.9 (4.3 SD) mm for the LCAA in the standard sutured group as well as 14.4 (3.9 SD) mm for the RCAA and 9.0 (3.1 SD) mm for the LCAA in the RD-AVR group were observed (P < 0.001 for RCAA and LCAA in both the sutured and rapid-deployment groups). Despite the significant difference in the mean distance from the left coronary artery to annulus between the groups at baseline, the postoperative mean distance of the LCAA to the sewing ring was still higher in the RD-AVR group.

CONCLUSIONS

A significantly shorter coronary artery-to-aortic annulus distance for both the right and left main coronary arteries was observed after AVR with different conventional sutured supra-annular bioprostheses compared to AVR with rapid-deployment valves. These findings might be relevant for bioprosthesis selection, especially for young patients.

First-in-man Valve-in-Valve with the new balloon-expandable Myval transcatheter heart valve in a failed sutureless Perceval bioprosthesis

Sutureless aortic bioprostheses were introduced more than ten years ago, with the aim of decreasing cross-clamp time and thus becoming the first choice in older patients for many surgeons. However, published data are limited to a 5-year follow-up, and some cases of deterioration have already been described. High-risk patients who once have benefitted from a fast sutureless aortic replacement and now are experiencing a prosthesis dysfunction, could take advantage of a percutaneous Valve-in-Sutureless technique. Furthermore, thanks to technological improvement, new transcatheter prostheses have been designed, allowing a more precise positioning. In this report, we described the first Myval-in-Perceval case, which resulted in a safe and effective procedure.

Allegra Transcatheter Heart Valve inside a Degenerated Sutureless Aortic Bioprosthesis

Transcatheter aortic valve-in-valve implantation (VIV) is increasingly being used to successfully treat degenerated surgical aortic valve bioprostheses (SAVs). The new self-expanding transcatheter heart valve Allegra, from New Valve Technology with its special implantation mechanism, has proven its safety and feasibility for patients with degenerated SAVs, but it has never been used in the latest-generation sutureless SAV. To the best of our knowledge, this is the first description of the successful VIV of the Allegra prosthesis into a degenerated sutureless SAV, and the procedure yielded an excellent postinterventional hemodynamic results.

Midterm outcomes with a sutureless aortic bioprosthesis in a prospective multicenter cohort study

OBJECTIVE

The objective of this study was to report midterm clinical outcomes with a self-expandable sutureless aortic valve.

METHODS

Between 2010 and 2013, 658 patients at 25 European institutions received the Perceval sutureless valve (LivaNova Plc, London, United Kingdom). Mean follow-up was 3.8 years; late cumulative follow-up was 2325.2 patient-years.

RESULTS

The mean age of the population was 78.3 ± 5.6 years and 40.0% (n = 263) were 80 years of age or older; mean Society of Thoracic Surgeons-Predicted Risk of Mortality score was 7.2 ± 7.4. Concomitant procedures were performed in 31.5% (n = 207) of patients. Overall duration of cardiopulmonary bypass time was 64.8 ± 25.2 minutes and aortic cross-clamping time was 40.7 ± 18.1 minutes. Thirty-day all-cause mortality was 3.7% (23 patients), with an observed:expected ratio of 0.51. Overall survival was 91.6% at 1 year, 88.5% at 2 years, and 72.7% at 5 years. Peak and mean gradients remained stable during follow-up, and were 17.8 ± 11.3 mm Hg and 9.0 ± 6.3 mm Hg, respectively, at 5 years. Preoperatively, 33.4% of those who received the Perceval valve (n = 210) were in New York Heart Association functional class I or II versus 93.1% (n = 242) at 5 years.

CONCLUSIONS

This series, representing, to our knowledge, the longest follow-up with sutureless technology in a prospective, multicenter study, shows that aortic replacement using sutureless valves is associated with low mortality and morbidity and good hemodynamic performance.

Systematic review and meta-analysis of valve-in-valve transcatheter aortic valve replacement in patients with failed bioprosthetic aortic valves

AIMS

The aim of this meta-analysis was to evaluate the evidence regarding the rates of procedural success and the incidence of adverse outcomes following valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) in patients with failed bioprosthetic aortic valves.

METHODS AND RESULTS

A systematic search of major electronic databases was conducted for studies relevant to patients with failed bioprosthetic aortic valves undergoing VIV-TAVR. The primary outcome was procedural success. A total of 5,553 patients from 24 studies were included. The mean Society of Thoracic Surgeons (STS) score was 7.84±5.14. The procedural success rate was high (97%, 95% confidence interval [CI]: 94-98%). At 30 days, all-cause mortality was 5% (95% CI: 3-6%), stroke 2% (95% CI: 1-2%), myocardial infarction 1% (95% CI: 1-2%), permanent pacemaker placement 6% (95% CI: 5-8%), and aortic regurgitation 7% (95% CI: 5-10%). At one year, the incidence of all-cause mortality was 12% (95% CI: 10-14%), stroke 3% (95% CI: 2-4%), myocardial infarction 1% (95% CI: 0-2%), and permanent pacemaker placement 7% (95% CI: 5-11%). At three years, the incidence of all-cause mortality was 29% (95% CI: 25-34%) and stroke 6% (95% CI: 5-9%).

CONCLUSIONS

VIV-TAVR appears to be associated with high procedural success rates and low adverse outcomes during the short-term and midterm follow-up period.

A series of four transcatheter aortic valve replacement in failed Perceval valves

In recent years, sutureless valves (SV) and rapid deployment valves (RDVs) have become interesting aortic valve substitutes, especially in minimally invasive aortic valve surgery, as they reduce cardio-pulmonary bypass and cross-clamp times. There are two valve types available, the sutureless Perceval and the rapid deployment Intuity valve prosthesis. When these valves fail, besides surgical re-replacement, the valve-in-valve concept has been reported in a small series of case reports. Our own experience includes four cases of failed Perceval valves, in which a balloon-expandable transcatheter valve was implanted in three patients, and a self-expanding transcatheter valve was implanted in a fourth patient. Here, we present these four cases with a focus on the specific valve design of the Perceval valve, as well as on important technical aspects. All cases were performed successfully with clinical improvement. Transcatheter aortic valve replacement (TAVR) as a valve-in-valve concept seems to be a valuable option in selected patients with failed sutureless or RDVs.

Outcome of rapid deployment aortic valves: long-term experience after 700 implants

Background

The Edwards Intuity Valve System is a bioprosthesis with a balloon-expandable stent frame which enables rapid-deployment (RD). We aimed to analyze our single-center long-term experience with a follow-up until 9 years after aortic valve replacement (AVR) with this bioprosthesis.

Methods

Between May 2010 and May 2019, 700 consecutive patients with severe aortic stenosis or combined aortic valve disease, implanted with a RD valve at our institution, were included in a prospective database. Median follow-up was 19 months and the total accumulated follow-up was 2,140 patient-years. Pre-operative characteristics, operative parameters, survival rates, valve-related adverse events and valve hemodynamics were assessed.

Results

Mean age was 74±8 years, 45% female. Concomitant procedures were performed in 339 (48.4%) patients. In case of isolated AVR (361/700), a minimally invasive surgical (MIS) approach was conducted in 283 patients (78.4%). Cardio-pulmonary bypass (CPB) and cross-clamp times for isolated AVR were 107.7±28.2 and 73.8±21.3 minutes for MIS approaches and 92.8±28.8 and 57.5±20.6 minutes for full sternotomy (P<0.001), respectively. Mean gradients at discharge, 1, 3 and 5 years were 13±5, 11±4, 12±5 and 13±8 mmHg. New early pacemaker implantation was required in 8.9% of patients. Re-intervention or re-operation with valve explantation for structural degeneration, non-structural dysfunction or endocarditis, occurred in 21 cases (3%). Thirty-day mortality was 0.7% (5/700) and overall survival at 1, 3 and 5 years was 98%, 91% and 76%.

Conclusions

We report excellent long-term results in this updated single center experience for RD aortic valves regarding durability, safety and hemodynamic performance.

Transcatheter Aortic Valve-in-Valve Implantation Complicated by Aorto-Right Ventricular Fistula

We describe the case of a degenerative, sutureless bioprosthetic valve (BPV) with deformation and stent infolding in a patient with elevated surgical risk. Following discussion among the heart team, balloon valve fracture was performed to facilitate deployment of an aortic valve-in-valve transcatheter heart valve. Post-procedural imaging demonstrated BPV frame protrusion and contained annular rupture, which required operative intervention. (Level of Difficulty: Intermediate.).