Sutureless Aortic Valve Replacement with Perceval Bioprosthesis Superior to Transcatheter Aortic Valve Implantation: A Promising Option for the Gray-Zone of Aortic Valve Replacement Procedures-A State-of-the-Art Systematic Review, Meta-Analysis, and Future Directions.

Background: The management of patients with aortic valve pathologies can sometimes fall into a "gray zone", where the optimal treatment approach is not straightforward. The comparative benefits of sutureless aortic valve replacement (SUAVR) using the Perceval bioprosthesis versus transcatheter aortic valve implantation (TAVI) for the "gray zone" of aortic valve replacement procedures remain a topic of debate. To further explore this issue, we conducted a study with pairwise, single-arm, and Kaplan-Meier-based meta-analyses to compare the outcomes of SUAVR with the Perceval bioprosthesis versus TAVI, as well as to evaluate the efficacy, safety, and durability of SUAVR with the Perceval bioprosthesis over mid-term and long-term follow-up periods. Methods: The PubMed, PubMed Central, OVID Medline, Cochrane Library, Embase, and Web of Science databases were systematically searched. All study types were included, except study protocols and animal studies, without time restrictions. The final search was carried out in May 2024. Results: No statistically significant differences were observed in permanent pacemaker implantation (PPI) rates between the two groups. SUAVR showed a lower incidence of new-onset myocardial infarction but was associated with higher rates of new-onset atrial fibrillation and major bleeding. TAVI had higher rates of left bundle branch block and major vascular complications. Conclusions: Our findings show that SUAVR has a lower incidence of complications and a favorable mid-term overall survival compared to TAVI. SUAVR has more advantages compared to TAVI and can be considered a valuable and promising option for the "grey zone" of aortic valve pathologies.

Ease of sutureless aortic valve replacement in a patient with unexpected ochronosis: a case report.

BACKGROUND: Alkaptonuria is a rare congenital metabolic disorder characterized by homogentisic acid accumulation in body cartilage and connective tissues due to a deficient homogentisic acid dioxygenase enzyme. This disorder manifests in various clinical symptoms, including spondyloarthropathy, ocular and dermal pigmentation, genitourinary tract obstruction by ochronosis stones, and cardiovascular system involvement. Cardiac ochronosis is a rare manifestation of alkaptonuria that may present as aortic stenosis, sometimes accompanied by other cardiovascular complications. CASE PRESENTATION: We report an unexpected case of ochronosis diagnosed during cardiac surgery. Due to the fragile, thin, and atheromatous nature of the ascending aorta in patients with ochronosis, we opted for a sutureless aortic valve replacement procedure. This approach appears to be more suitable for patients with ochronosis. CONCLUSIONS: Although cardiac ochronosis is rare, surgeons should remain vigilant and consider the possibility of this condition when examining patients with aortic valve stenosis, paying close attention to the clinical manifestations of alkaptonuria.

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.

Perceval sutureless bioprosthesis versus Perimount sutured bioprosthesis for aortic valve replacement in patients with aortic stenosis: a retrospective, propensity-matched study.

BACKGROUND: Rapid-deployment aortic valve replacement (RDAVR) is an alternative to conventional AVR (cAVR) for aortic stenosis. Benefits include a reduction in operative times, facilitation of minimal access surgery and superior haemodynamics compared to conventional valves. However, further evidence is required to inform guidelines, preferably in the form of propensity-matched studies that include mid-term follow-up data. METHODS: This was a single-centre, retrospective, propensity-matched cohort study comparing the Perceval and conventional Perimount Magna Ease valve for short- and mid-term clinical parameters and size-matched mid-term echocardiographic parameters (n = 102 in both groups) from 2014 to 2020. Data were extracted from a nationally managed dataset. RESULTS: There were no demographic differences between the matched groups. The Perceval group had shorter cross-clamp time (Perceval 62 [49-81] minutes; Perimount 79 [63-102] minutes, P < 0.001), shorter bypass time (Perceval 89 [74-114] minutes; Perimount 104 [84-137] minutes, P < 0.001), and more frequent minimally-invasive approaches (Perceval 28%; Perimount 5%, P < 0.001). Size-matched haemodynamics showed initially higher gradients in the Perceval group, but haemodynamics equalised at 12 + months. The Perceval group had a more favourable % change in the left ventricular posterior wall dimension at 2 + years (Perceval - 4.8 ± 18; Perimount 17 ± 2). CONCLUSIONS: The Perceval facilitated shorter operations, which may benefit intermediate-high-risk, elderly patients with comorbidities requiring concomitant procedures. It also facilitated minimally invasive surgery. Size-matched haemodynamic performance was similar at mid-term follow-up, with the Perceval possibly better facilitating regression of left ventricular hypertrophy.

Thrombocytopenia Following Perceval Sutureless Aortic Valve Replacement in Asian Patients.

BACKGROUND: This study analyzed the safety and performance of the Perceval valve for aortic valve replacement (AVR) in patients at 1 year after undergoing aortic stenosis (AS) treatment, and its effect on significant declines in the platelet count during the immediate postoperative period.Methods and Results: Data were collected retrospectively for the initial 121 patients (median age 77 years; 47.1% females) who underwent Perceval sutureless AVR between May 2019 and July 2022. Implantation was successful in all (100%), with median cross-clamp and CPB times of 59 and 100 min, respectively. Postoperative thrombocytopenia (platelet count <50×103/µL) was noted in 80 (66.1%) patients. Multivariate analysis showed advanced age (>80 years), preoperative low platelet count (<200×103/µL), and a sternotomy approach as significant risk factors for postoperative thrombocytopenia. One (0.8%) patient died within 30 days after the procedure. The 2-year site-reported event rate was 14% (n=17) for all-cause mortality, 0.8% (n=1) for cardiac mortality, 4.1% (n=5) for stroke, and 1.7% (n=2) for endocarditis and valve-related reoperation; there were no instances of paravalvular leakage or structural valve deterioration. CONCLUSIONS: Thrombocytopenia was common after Perceval sutureless AVR, although its impact was not significant. Although Perceval sutureless AVR was found to be a safe and effective option, preoperative assessment of potential bleeding should be performed and the Perceval valve should not be used for patients with a high bleeding risk.

Perceval valve intermediate outcomes: a systematic review and meta-analysis at 5-year follow-up.

OBJECTIVES: New technologies for the treatment of Aortic Stenosis are evolving to minimize risk and treat an increasingly comorbid population. The Sutureless Perceval Valve is one such alternative. Whilst short-term data is promising, limited mid-term outcomes exist, until now. This is the first systematic review and meta-analysis to evaluate mid-term outcomes in the Perceval Valve in isolation. METHODS: A systematic literature review of 5 databases was performed. Articles included evaluated echocardiographic and mortality outcomes beyond 5 years in patients who had undergone Perceval Valve AVR. Two reviewers extracted and reviewed the articles. Weighted estimates were performed for all post-operative and mid-term data. Aggregated Kaplan Meier curves were reconstructed from digitised images to evaluate long-term survival. RESULTS: Seven observational studies were identified, with a total number of 3196 patients analysed. 30-day mortality was 2.5%. Aggregated survival at 1, 2, 3, 4 and 5 years was 93.4%, 89.4%, 84.9%, 82% and 79.5% respectively. Permanent pacemaker implantation (7.9%), severe paravalvular leak (1.6%), structural valve deterioration (1.5%), stroke (4.4%), endocarditis (1.6%) and valve explant (2.3%) were acceptable at up to mid-term follow up. Haemodynamics were also acceptable at up mid-term with mean-valve gradient (range 9-13.6 mmHg), peak-valve gradient (17.8-22.3 mmHg) and effective orifice area (1.5-1.8 cm2) across all valve sizes. Cardiopulmonary bypass (78 min) and Aortic cross clamp times (52 min) were also favourable. CONCLUSION: To our knowledge, this represents the first meta-analysis to date evaluating mid-term outcomes in the Perceval Valve in isolation and demonstrates good 5-year mortality, haemodynamic and morbidity outcomes. KEY QUESTION: What are the mid-term outcomes at up to 5 years follow up in Perceval Valve Aortic Valve Replacement? KEY FINDINGS: Perceval Valve AVR achieves 80% freedom from mortality at 5 years with low valve gradients and minimal morbidity. KEY OUTCOMES: Perceval Valve Aortic Valve Replacement has acceptable mid-term mortality, durability and haemodynamic outcomes.

Left Coronary Ostial Obstruction by a Dislocated Sutureless Aortic Valve Prosthesis: Redo Aortic Valve Replacement with Hybrid Coronary Revascularization: A Case Report.

Coronary ostium obstruction due to dislodgement of the prosthetic valve is a rare and life-threatening complication, and particular caution is required for sutureless aortic valve replacement (AVR) with concomitant valvular surgery. In general, coronary artery bypass surgery is performed when coronary ostium obstruction occurs after AVR, but other options may need to be considered in some cases. Herein, we present a case of coronary artery occlusion in an 82-year-old female patient who had undergone AVR and mitral valve replacement for aortic valve stenosis and mitral valve stenosis at the age of 77 years. A hybrid procedure involving redo AVR and percutaneous coronary intervention after left main coronary ostium endarterectomy was performed. To summarize, we present a case of hybrid AVR in a patient with coronary artery obstruction after AVR that was successfully managed using this method.

Easy surgical explantation technique for sutureless Perceval S prosthesis, 'lasso technique': a case report.

BACKGROUND: Due to structural valve deterioration of sutureless aortic prosthesis, there is a need for explantation of the prothesis. We introduce a surgical technique to explant sutureless aortic prosthesis, which has a self-expanding stent incorporated into the aortic wall. CASE PRESENTATION: An 82-year-old man who had undergone sutureless aortic valve replacement 6 years previously underwent redo-aortic and mitral valve replacement because of severe prosthetic aortic valve stenosis and mitral regurgitation. The sutureless prosthesis was explanted using 'lasso technique'. The patient was discharged after 7 days without complications. CONCLUSIONS: We presented a useful technique to explant a sutureless aortic prosthesis.

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

OBJECTIVE: The aim of this study was to evaluate the outcome and experience of the Perceval sutureless valve at our institution (UZ Leuven). METHODS: Between 2007 and 2019, 784 patients underwent sutureless aortic valve replacement using the Perceval valve (isolated or combined with other procedures). We performed a retrospective analysis of the postoperative and follow-up data. RESULTS: Mean age was 78 years with a median European System for Cardiac Operative Risk Evaluation II score of 4.2% (interquartile range, 2.6%-7.2%). Isolated aortic valve replacement accounted for 45% of cases; 30% of cases were aortic valve replacement in combination with coronary artery bypass grafting and the remaining 25% were other combined procedures. The median crossclamp times were 38 minutes in single aortic valve replacement, 70 minutes in cases with coronary artery bypass grafting, and 89 minutes in multiple valve cases. Device success was 99.1% and in-hospital mortality was 3.3%. Postoperative stroke or transient ischemic attack occurred in 1.9% of patients and 1% of patients had a new need for dialysis after surgery and median survival time was 7.0 years with a cumulative follow-up of 2797.8 patient-years. The 1-, 5-, and 10-year freedom from reintervention were 99%, 97%, and 94%, respectively. CONCLUSIONS: These data represent the longest follow-up available, to our knowledge, for the Perceval sutureless valve. We observed favorable early outcomes, and low rates of early mortality, stroke, and other major complications. Valve durability is promising with low rates of valve degeneration and a limited need for reintervention.

Sutureless aortic valve replacement in high-risk patients with active infective endocarditis.

Background: Surgical aortic valve replacement remains the gold standard of treatment in patients with active infective endocarditis. Such procedures tend to carry a significantly higher operative risk when compared to the conventional aortic valve replacement for a non-infective aortic valve disease. Sutureless aortic valve replacement (SU-AVR) has been introduced into cardiac surgery to allow for a simpler implementation of minimally invasive procedures. Although SU-AVR in several extended indications has proven to be successful, the data on the implementation of SU-AVR in patients with infective aortic valve endocarditis remain scarce. The aim of the study was to examine the feasibility of SU-AVR in high-risk patients with active infective aortic valve endocarditis. Methods: Between December 2019 and March 2022, a total of 151 consecutive patients underwent a SU-AVR for various indications at our institution. Of those, in 13 consecutive high-risk patients SU-AVR was indicated because of infective aortic valve endocarditis. In all cases Perceval S aortic valve prosthesis (Corcym, Saluggia, Italy) was used and the implantation has been performed with Snugger-method. Results: The mean age of the patients at operation was 74.05±11.6 years. Eight of the patients suffered from prosthesis endocarditis while the other five patients presented with the endocarditis of the native aortic valve. All patients suffered from multiple comorbidities, as reflected by a mean logistic EuroSCORE of 47.9%±23.1% and EuroSCORE II of 28.7%±22.0%. In 8 patients (61.5%) a concomitant procedure was necessary. Also 8 patients (61.5%) underwent a redo procedure. Bypass- and cross-clamp (CC) times were 89.8±33.6 and 59.1±27.8 minutes, respectively. We observed no paravalvular leakage and no cases of left-ventricular outflow tract obstruction. Postoperative mean gradients after SU-AVR implantation were 8.1±4.8 mmHg. Conclusions: SU-AVR in patients presenting with active infective endocarditis is a safe and feasible surgical alternative to the conventional operation. Clearly, this operative approach should be considered particularly for high-risk patients in whom successful operative outcomes are determined by a reduction in bypass and CC time. SU-AVR provides excellent hemodynamic performance with a low risk of paravalvular leakage and low transvalvular gradients, whilst simplifying the surgical procedure.

Aortic annulus rupture with fistula to the right ventricle following aortic valve replacement with a sutureless valve: A surgical complication with a percutaneous solution.

With the development of interventional procedures, iatrogenic aorto-right ventricular fistulae are increasingly reported. They may follow surgical aortic valve replacement or percutaneous aortic valve implantation, leading to high morbidity. Traditionally, treatment of fistulae was based on surgical repair, but with advances in endovascular technologies, more emphasis is now placed on percutaneous closure. We report the case of a 78-year-old patient with severe symptomatic aortic stenosis who underwent surgical aortic valve replacement with a Perceval sutureless valve. One month later, he presented with symptoms and signs of heart failure. Transthoracic and transesophageal echocardiography confirmed the presence of a aorto-right ventricular fistula. The fistula was successfully closed percutaneously with an Amplatzer Vascular Plug II, in an intracardiac echocardiography-guided procedure. Aorto-right ventricular fistula is a rare finding after surgical aortic valve replacement and to our knowledge it has never been associated with sutureless aortic valve replacement. A percutaneous procedure with an appropriately selected device may be encouraged because of the high morbidity and mortality of redo open-heart surgery. To minimize the risk of a second general anesthesia, the use of intracardiac echocardiography to guide the percutaneous procedure is feasible and safe.

A survey of cardiac surgeons to evaluate the use of sutureless aortic valve replacement in Canada.

BACKGROUND: Sutureless aortic valve replacement (SuAVR) is gaining popularity for the treatment of aortic stenosis. We aimed to describe Canadian cardiac surgeons' practice patterns and perceptions regarding SuAVR. METHODS: Content experts (clinicians and methodologists) developed the survey. Domains in the questionnaire include: respondent characteristics, factors influencing the decision to implant a SuAVR, barriers to SuAVR use, and interest in participating in a trial. RESULTS: A total of 66 cardiac surgeons (median duration of practice: 15 years; range 8-20 years) from 18 hospitals across Canada responded to the survey for a response rate of 84%. Surgeons reported that the following patient characteristics increased the likelihood they would choose SuAVR: hostile root (73%), small annular size (55%), high Society of Thoracic Surgery risk score (42%), older age (40%), to support minimally invasive surgery (25%) and redo-operation (23%). The following patient characteristics made surgeons less likely to pursue SuAVR: young age (73%), low STS score (40%), and large annular size (30%). Reported barriers to SuAVR use included: cost (33%), permanent pacemaker risk (27%) and uncertain durability (12%). Of respondents, 73% were interested in participating in a randomized controlled trial comparing SuAVR with transcatheter aortic valve replacement. CONCLUSIONS: The primary reasons for surgeons selecting SuAVR were high surgical risk and anatomical challenges. Cost is a primary factor limiting SuAVR use.

Transcatheter Aortic Valve Replacement versus Sutureless Aortic Valve Replacement: A Single Center Retrospective Cohort Study.

PURPOSE: This study sought to compare clinical outcomes between transcatheter aortic valve replacement (TAVR) and sutureless aortic valve replacement (SU-AVR). MATERIALS AND METHODS: In total, 320 patients with symptomatic severe aortic stenosis who underwent TAVR (n=254) or SU-AVR (n=66) at Severance Cardiovascular Hospital between July 2011 and September 2019 were included for analysis. Propensity score matching and inverse probability weighted adjustment were performed to adjust for confounding baseline characteristics. Outcomes defined by the Valve Academic Research Consortium-2 in 62 patients pairs were compared. RESULTS: Device success (79.0% vs. 79.0%, p>0.999) and 30-day mortality (4.8% vs. 0.0%, p=0.244) did not differ between the TAVR and SU-AVR groups. The TAVR group developed more frequent mild or moderate paravalvular leakage (59.7% vs. 8.1%, p<0.001), whereas SU-AVR was associated with higher rates of major or life-threatening bleeding (9.7% vs. 22.6%, p=0.040), acute kidney injury (8.1% vs. 21.0%, p=0.041), and new-onset atrial fibrillation (4.8% vs. 32.3%. p<0.001) at 30 days, along with longer stays in the intensive care unit (ICU) (1.9±1.6 days vs. 5.9±9.2 days, p=0.009) and hospital (7.1±7.9 days vs. 13.1±8.8 days, p<0.001). The TAVR group showed a trend towards a higher 1-year all-cause mortality, compared with the SU-AVR group (7.0% vs 1.7%, p=0.149). Cardiovascular mortality, however, did not differ significantly (1.6% vs 1.7%, p=0.960). CONCLUSION: TAVR achieved a similar 1-year survival rate free from cardiovascular mortality as SU-AVR and was associated with a lower incidence of complications, except for paravalvular leakage, and shorter stays in the ICU and hospital.

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

BACKGROUND: This study aimed to evaluate the early outcomes of Perceval sutureless valves in the Korean population and to introduce a modified technique of guiding suture placement during valve deployment.Methods and Results:From December 2014 to April 2019, 121 patients (mean age: 74.7±6.2 years; 53.7% female) received a Perceval sutureless aortic valve replacement. To prevent conduction system injury, the depth of guiding suture placement (1 mm below the nadir of the annulus) was modified. All patients underwent echocardiographic evaluation at discharge and 6-12 months postoperatively, with a mean follow up of 13.7±11.2 months. Concomitant surgeries, such as coronary artery bypass grafting, and other valvular surgeries, were performed in 45.5% of cases. The mean aortic cross-clamp times for isolated and minimal procedures were 32.8±7.9, and 41.2±8.0 min, respectively. The overall transvalvular mean gradients were 13.1±3.8 mmHg at discharge and 11.5±4.7 mmHg at the last follow up. After modifying the guiding suture placement, permanent pacemaker implantation risk decreased from 9.9% to 2.5%. Cardiac-related mortality was 0.8%, with no patient developing valvular or paravalvular aortic regurgitation, valve thrombosis, or endocarditis. CONCLUSIONS: Perceval valve implantation provided a significant cardiac-related survival benefit with excellent early hemodynamic and clinical outcomes. Further research is needed to determine whether adjusting the implantation depth, such as modification of the guiding suture technique, can reduce the risk of permanent pacemaker implantation.

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

BACKGROUND: We compared early and 2-year clinical outcomes of sutureless aortic valve replacement (SAVR) with conventional aortic valve replacement (CAVR) in a nationwide study based on claims data. METHODS: From December 2016 to November 2018, 3,173 patients underwent bioprosthetic aortic valve replacements. SAVR and CAVR were performed in 641 and 2,532 patients, respectively. Propensity score-matched analysis was performed in 640 patient pairs. RESULTS: Operative mortality rate was 2.8% without significant differences between the SAVR (3.4%) and CAVR (2.3%) groups (P = 0.324). There were no significant differences in postoperative morbidities between the groups except for permanent pacemaker (PPM) implantation. PPM implantation rate was significantly higher in the SAVR (3.8%) than in the CAVR group (0.9%) (P < 0.001). One- and two-year overall survival was 89.1% and 87.5%, respectively, without significant differences between the groups (SAVR group vs. CAVR grouP = 89.9% and 90.5% vs. 87.2% and 88.7%, respectively; P = 0.475). There were no significant differences in the cumulative incidence of cardiac death, stroke, aortic valve reoperation and infective endocarditis between the groups. Cumulative PPM implantation incidence at 6 months in the CAVR was 1.1%, and no patient required PPM implantation after 6 months. In the SAVR, the cumulative PPM implantation incidence at 0.5, one, and two years was 3.9%, 5.0% and 5.6%, respectively. The cumulative PPM implantation rate was higher in the SAVR group than in the CAVR group (P < 0.001). CONCLUSION: Early and 2-year clinical outcomes between SAVR and CAVR were not different except for a high rate of permanent pacemaker implantation in the SAVR group.

Predictors of Pacemaker Insertion Post-Sutureless (Perceval) Aortic Valve Implantation.

INTRODUCTION: The use of rapid deployment sutureless aortic valve replacement (AVR) has become a viable alternative to conventional AVR especially in intermediate and high-risk patients. However, sutureless AVR has been associated with increased rates of permanent pacemaker (PPM) implantation compared with conventionally implanted aortic valve prostheses. The aim of this study was to determine predictive factors for complete heart block requiring insertion of a PPM post-AVR with a Perceval S sutureless valve (LivaNova, London, UK). Such knowledge will help to improve patient counselling, selection and management of patients undergoing sutureless AVR. METHODOLOGY: A retrospective cohort study assessed all patients who underwent insertion of the Perceval sutureless aortic valve prosthesis between July 2015 and September 2019. Medical records were reviewed for demographic, preoperative electrocardiograph (ECG), and operative features related to postoperative PPM implantation and follow-up in the electrophysiology clinic. RESULTS: One hundred and thirty (130) patients without pre-existing PPM underwent sutureless AVR (66.9% male, average age 74.4±6.6 years). Fifty-seven (57) underwent concomitant cardiac surgical procedures. Eight (8) patients underwent redo cardiac surgery. Nineteen (19) of the 130 (14.6%) patients required insertion of a PPM during their postoperative course. Factors associated with PPM insertion were right bundle branch block (overall n=15, PPM vs No PPM: 8/19 vs 7/111 [42.1 % vs. 6.31 %; p<0.01]), longer QRS duration 113.32ms±22.24 ms vs 100.52±20.96 ms (p=0.017) and longer PR Interval 185.166±42.38 ms vs 169.23±25.70 ms (p=0.03). CONCLUSION: Insertion of rapid deployment sutureless aortic valves in the setting of pre-existing right bundle branch block, prolonged QRS complex and longer PR intervals is associated with increased risk of postoperative PPM requirement. These factors should be considered when preoperatively counselling and postoperatively managing patients when balloon expandable sutureless valves are used.

Conduction disorders after aortic valve replacement: what is the real impact of sutureless and rapid deployment valves?

BACKGROUND: Although sutureless and rapid deployment aortic valve replacement (SURD-AVR) has been associated with an increased rate of permanent pacemaker (PPM) implantation compared to conventional AVR (c-AVR), the predictors of new conduction abnormalities remain to be clarified. This study aimed to identify risk factors for conduction disorders in patients undergoing AVR surgery. METHODS: Data from 243 patients receiving minimally invasive AVR were prospectively collected. SURD-AVR was performed in 103 (42.4%) patients and c-AVR in 140 (57.6%). The primary endpoint was the occurrence of new-onset conduction disorders, defined as first degree atrioventricular (AV) block, advanced AV block requiring PPM implantation, left anterior fascicular block (LAFB), left bundle branch block (LBBB) and right bundle branch block (RBBB). RESULTS: The unadjusted comparison revealed that SURD-AVR was associated with a higher rate of advanced AV block requiring PPM when compared with c-AVR (10.5% vs. 2.1%, P=0.01). After adjusting for other measured covariates (OR: 1.6, P=0.58) and for the estimated propensity of SURD-AVR (OR: 5.1, P=0.1), no significant relationship between type of AVR and PPM implantation emerged. On multivariable analysis, preoperative first-degree AV block (OR: 6.9, P=0.04) and RBBB (OR: 6.9, P=0.03) were independent risk factors for PPM. Subgroup analysis of patients with normal preoperative conduction revealed similar incidence of PPM between SURD-AVR and c-AVR (1.3% vs. 1.9%, P=0.6). When compared with c-AVR, SURD-AVR was associated with a greater incidence of postoperative new onset LBBB (18.1% vs. 3.2%, P<0.001). This finding was confirmed after adjusting for the estimated propensity of SURD-AVR (OR: 6.3, P=0.009). CONCLUSIONS: Our study revealed that the risk of PPM implantation in patients receiving surgical AVR is heavily influenced by the presence of pre-existing conduction disturbances rather than the type of valve prosthesis. Conversely, SURD-AVR emerged as an independent predictor for LBBB and was associated with an increased risk of PPM in patients presenting with RBBB.

A case of challenging percutaneous coronary intervention following surgical aortic valve replacement with a sutureless aortic bioprosthesis.

A 71-year-old man with symptomatic severe aortic valve stenosis and stenosis of the proximal right coronary artery (RCA) underwent aortic valve replacement with Perceval (LivaNova, London, UK), a sutureless aortic bioprosthesis with a self-expanding open-cell designed nitinol frame (SL-AVR). Seven weeks after the SL-AVR, percutaneous coronary intervention (PCI) to the RCA was required. However, engagement of the guiding catheter (GC) was challenging because the RCA ostium was jailed by the strut of the Perceval. Therefore, the "Mother, Child, and Grandchild Technique" was used. A 4-Fr diagnostic catheter (DC) was partially engaged, and a support type 0.014-inch guidewire (GW) was inserted into the distal RCA. The DC was replaced by a 6-Fr GC. To fill the gap between the 0.014-inch GW and 6-Fr GC, a 5-Fr tapered inner sheath (IS, tip size was 3.0-Fr, used as Child catheter) was inserted into the 6-Fr GC (Mother catheter), and a 2.6-Fr microcatheter (Grandchild catheter) was inserted into the 5-Fr IS. Therefore, the gap between the 0.014-inch GW and 6-Fr GW was obliterated. Finally, we successfully inserted the PCI system and engaged the GC. RCA stenosis was treated using the conventional PCI technique. Herein, we report a case of successful PCI subsequent to SL-AVR. .

Critical Left Main Coronary Stenosis After Sutureless Aortic Valve Replacement.

Our case illustrates the feasibility of high-risk PCI to salvage LMCA stenosis, possibly caused by coronary injury during direct coronary cardioplegia for a recent triple-valve operation.

Electrocardiographic and clinical predictors of permanent pacemaker insertion following Perceval sutureless aortic valve implantation.

BACKGROUND: Sutureless aortic valve replacement surgery (AVR) is a reasonable alternative surgical approach in those patients with aortic stenosis who would benefit from reduced cross clamp time, such as elderly and high-risk patients. We sought to evaluate the incidence of pacemaker (PM) implantation following sutureless AVR and to analyse possible pre-operative electrocardiographic and clinical predictors of PM implantation. METHODS AND RESULTS: Between November 2013 and March 2015, 58 patients (male 43%, age 77.9 ±â€¯4.9 years) having undergone sutureless AVR with a Perceval prosthesis (Sorin Biomedica Cardio Srl, Saluggia, Italy) were taken into consideration for our analysis. During a mean follow up of 13.8 ±â€¯5.0 months (median 13 months), 14 patients (24.1%) underwent pacemaker (PM) implantation following sutureless AVR procedure. Among these patients, 12 (86%) presented III degree atrioventricular (AV) block, 1 (7%) presented II degree AV block, and remaining one (7%) severe symptomatic bradycardia. The comparison of pre-operative characteristics between PM group and no PM group highlighted that QRS duration, EuroSCORE II index and chronic renal dysfunction were significantly associated with the development of AV conduction abnormalities/symptomatic bradycardia requiring PM implantation (respectively, p = 0.01, p = 0.02 and p = 0.03). CONCLUSIONS: The incidence of PM implantation after sutureless AVR was 24.1% in the present study. The EuroSCORE II, QRS duration and renal dysfunction were significantly associated with higher risk of AV conduction abnormalities/symptomatic bradycardia requiring PM placement.