Sutureless Sorin Perceval Aortic Valve Implantation

The Hemodynamic Performance of the Perceval Sutureless Aortic Valve in a Propensity-Matched Comparison to the Carpentier-Edwards Perimount and Perimount Magna Ease Valves for Aortic Valve Replacement

OBJECTIVES

The Perceval valve was shown to facilitate minimal-invasive operations and shorten operative times. We aimed to compare the early results of the Perceval valve to those of well-established valves, namely the Carpentier-Edwards Perimount and Perimount Magna Ease valve protheses, in terms of their clinical and hemodynamic performances.

METHODS

This is a single-center, retrospective, observational cohort study. For every patient operated with a Perceval valve, the last patient before and the next following patient receiving a Perimount valve was included in a control group leading to a 2:1 ratio (Perimount:Perceval). A propensity score matching was used and a subgroup analysis was performed to compare early and late Perceval patients as the sizing technique was changed over time.

RESULTS

From November 2013 to November 2017, 423 patients were identified. These included 141 consecutive patients receiving a Perceval valve through a full- or a hemi-sternotomy. In addition, 282 patients receiving a Perimount or a Magna Ease valve were enrolled. After propensity score matching, 127 matched patients were compared. Operating times were shorter and postoperative transvalvular pressure gradients were lower in the Perceval group (15 vs. 17 mmHg, p = 0.002). There was no difference in mortality and stroke rates. The incidence of new pacemaker implantations was higher in the Perceval group (7.1 vs. 18.9%, p = 0.005), mainly due to a very high incidence in the early phase of our Perceval experience prior to a change in the Perceval implantation technique. Subgroup analysis showed significantly better results in the late Perceval group.

CONCLUSION

Surgical outcome was good in both groups. The Perceval valve exhibited lower postoperative gradients, and the need for pacemaker implantation was higher and can be reduced by avoiding oversizing.

Sutureless bioprosthesis for aortic valve replacement: Surgical and clinical outcomes

BACKGROUND

Aortic valve stenosis is the most common adult valve disease in industrialized countries. The aging population and the increase in comorbidities urge the development of safer alternatives to the current surgical treatment. Sutureless bioprosthesis has shown promising results, especially in complex procedures and in patients requiring concomitant surgeries.

OBJECTIVES

Assess the clinical and hemodynamic performance, safety, and durability of the Perceval® prosthetic valve.

METHODS

This single-center retrospective longitudinal cohort study collected data from all adult patients with aortic valve disease who underwent aortic valve replacement with a Perceval® prosthetic valve between February 2015 and October 2020. Of the 196 patients included (mean age 77.20 ± 5.08 years; 45.4% female; mean EuroSCORE II 2.91 ± 2.20%), the majority had aortic stenosis.

RESULTS

Overall mean cross-clamp and cardiopulmonary bypass times were 33.31 ± 14.09 min and 45.55 ± 19.04 min, respectively. Mean intensive care unit and hospital stay were 3.32 ± 3.24 days and 7.70 ± 5.82 days, respectively. Procedural success was 98.99%, as two explants occurred. Four valves were reimplanted due to intraoperative misplacement. Mean transvalvular gradients were 7.82 ± 3.62 mmHg. Pacemaker implantation occurred in 12.8% of patients, new-onset atrial fibrillation in 21.9% and renal replacement support was necessary for 3.1%. Early mortality was 2.0%. We report no structural valve deterioration, strokes, or endocarditis, and one successfully treated valve thrombosis.

CONCLUSIONS

Our study confirms the excellent clinical and hemodynamic performance and safety of a truly sutureless aortic valve, up to a 5-year follow-up. These results were consistent in isolated and concomitant interventions, solidifying this device as a viable option for the treatment of isolated aortic valve disease.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSIONS

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

Perioperative platelet reduction after sutureless or stented valve implantation: results from the PERSIST-AVR controlled randomized trial

OBJECTIVES

Platelet count reduction is a common but not fully understood phenomenon after aortic valve replacement (AVR) with bioprosthesis implantation. The aim of the present study was to investigate the occurrence and the clinical impact of platelet count reduction in patients receiving the Perceval bioprosthesis compared to those receiving standard sutured stented bioprosthetic aortic valve in a randomized, controlled AVR study.

METHODS

PERceval Sutureless Implant versus STandard Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016-September 2018) to AVR with a sutureless or stented valve. Ad hoc analyses have been performed to evaluate the occurrence of platelet count reduction and the clinical impact of the platelet variations in the 2 groups.

RESULTS

The Perceval group showed a higher platelet reduction than the control group (46% vs 32%). The phenomenon was transient in both groups, with a slow recovery of the platelet count by hospital discharge. No differences were observed between groups regarding need of transfusions, blood loss, major bleeding and stroke events.

CONCLUSIONS

The Perceval sutureless aortic bioprosthesis implantation is associated with higher rate of transient platelet reduction as compared to stented bioprostheses for AVR. However, the platelet count reduction is transient and the decline does not affect the patient's clinical outcomes. Current explanations for this phenomenon are speculative, and further investigations are required to elucidate it.

CLINICAL TRIAL REGISTRATION NUMBER

NCT02673697-ClinicalTrials.gov-4 February 2016.

Perceval S valve empire: healing the Achilles' heel of sutureless aortic valves

Aortic valve replacement is the treatment of choice concerning aortic valve disease. Excellent short- and longterm clinical results are reported. Patients referred for aortic valve replacement are getting older and older, so bioprosthetic valves play a more central role worldwide. However, patient comorbidities are also increased more often rendering patients unsuitable for open conventional aortic valve replacement. As a result, transcatheter aortic valve implantation has become the treatment of choice in patients at very high surgical risk. However, the percutaneous technique is related to major disadvantages provided that the diseased native valve is left in place. Its durability is also uncertain. More recently, sutureless Perceval S valve bioprosthesis has gained ground in the field of aortic stenosis therapy filling the gap between conventional aortic valve replacement and transcatheter approach. Excellent haemodynamic and clinical results are reported. Its deployment is performed under direct view and ischemic and overall operative times are significantly decreased. Five-year follow-up results are also optimal. However, the "Achilles' heel" of sutureless technology is increased rates of postoperative permanent pacemaker implantation requirement compared to conventional approach. The incidence of this complication varies in literature. Patient-related factors such as preoperative conduction disorders, older age and short membranous septum are predictors of postoperative pacemaker requirement. However, several technical modifications with regard to manufacturer recommendations can be adopted to mitigate this complication. Appropriate annular decalcification, higher guiding sutures placement, reduced balloon pressure and duration and avoiding of oversizing can contribute to prevent from this complication.

[Current problems of simultaneous surgery of the aortic valve and ischaemic heart disease]

Surgical policy in treatment of patients suffering from concomitant valvular pathology and ischaemic heart disease is an extremely important problem of contemporary cardiac surgery. With the advent of advanced techniques and due to the improvement of old ones, there have over the last decades appeared new approaches to treatment of this cohort of patients. Presented in the article is a review of current publications regarding the problem of surgical treatment of patients with a combination of pronounced valvular pathology requiring surgical correction and ischaemic heart disease necessitating the need for myocardial revascularization. This is followed by providing the data concerning contemporary strategies of treatment of patients with concomitant pathology, as well as the comparison of various approaches and the effect of the chosen technique on the outcome.

Sutureless versus conventional bioprostheses for aortic valve replacement in severe symptomatic aortic valve stenosis

OBJECTIVE

Sutureless aortic valves are a novel option for aortic valve replacement. We sought to demonstrate noninferiority of sutureless versus standard bioprostheses in severe symptomatic aortic stenosis.

METHODS

The Perceval Sutureless Implant Versus Standard-Aortic Valve Replacement is a prospective, randomized, adaptive, open-label trial. Patients were randomized (March 2016 to September 2018) to aortic valve replacement with a sutureless or stented valve using conventional or minimally invasive approach. Primary outcome was freedom from major adverse cerebral and cardiovascular events (composite of all-cause death, myocardial infarction, stroke, or valve reintervention) at 1 year.

RESULTS

At 47 centers (12 countries), 910 patients were randomized to sutureless (n = 453) or conventional stented (n = 457) valves; mean ages were 75.4 ± 5.6 and 75.0 ± 6.1 years, and 50.1% and 44.9% were female, respectively. Mean ± standard deviation Society of Thoracic Surgeons scores were 2.4 ± 1.7 and 2.1 ± 1.3, and a ministernotomy approach was used in 50.4% and 47.3%, respectively. Concomitant procedures were performed with similar rates in both groups. Noninferiority was demonstrated for major adverse cerebral and cardiovascular events at 1 year, whereas aortic valve hemodynamics improved equally in both groups. Use of sutureless valves significantly reduced surgical times (mean extracorporeal circulation times: 71.0 ± 34.1 minutes vs 87.8 ± 33.9 minutes; mean crossclamp times: 48.5 ± 24.7 vs 65.2 ± 23.6; both P < .0001), but resulted in a higher rate of pacemaker implantation (11.1% vs 3.6% at 1 year). Incidences of perivalvular and central leak were similar.

CONCLUSIONS

Sutureless valves were noninferior to stented valves with respect to major adverse cerebral and cardiovascular events at 1 year in patients undergoing aortic valve replacement (alone or with coronary artery bypass grafting). This suggests that sutureless valves should be considered as part of a comprehensive valve program.

Degenerated Suturless Perceval with (Paravalvular Leak and AS) Treated by Valve in Valve using S3 Edward Valve

A 70-year-old female patient, known to be diabetic and hypertensive, was diagnosed with coronary artery disease and severe aortic stenosis aortic valve area 0.5 cm, peak gradient of 110 mmHg, mean gradient 55 mmHg). This patient underwent coronary artery bypass graft with two grafts and artery bypass grafting in 2012. She received a sutureless Perceval aortic valve with good postoperative results except for a small jet of paravalvular leak. She did well for 5 years until she began experiencing dyspnea on exertion. The patient was found to have moderate to severe aortic regurgitation and moderate aortic stenosis which progressed over the years with multiple admissions for heart failure and pulmonary edema. The patient was considered high risk for operative treatment. Therefore, she was treated by percutaneous valve-in-valve technique using S3 Edward valve with excellent results.

Outcome of a Modified Perceval Implantation Technique

Background In our institution, we developed a modification of the standard implantation technique of the Perceval sutureless aortic prosthesis (LivaNova, London, United Kingdom) that involves the usage of snuggers for the guiding sutures during valve deployment. The technique has been described elsewhere. In this article, we present the results of our initial case series comprising 128 consecutive patients.

Methods From September 2016 to June 2018, 128 patients received a sutureless Perceval prosthesis (mean age 72.2 ± 8.5 years, 66 males). The data of the patients were prospectively collected in our general database and retrospectively analyzed using the SPSS software version 25 (IBM SPSS Inc., Chicago, Illinois, United States). Primary end points were primary implantation success and 30-day mortality. All patients underwent transthoracic echocardiography on discharge.

Results Our cohort consisted of real-world scenario patients with infective endocarditis, bicuspid aortic valves and one patient with left ventricular assist device. However, we had 100% primary implantation success with no need for valve explantation or paravalvular leaks. All-cause 30-day mortality was 2.3% (3 patients) with no cardiac deaths. Two patients (1.6%) had a permanent neurological deficit, three patients (2.3%) had new-onset renal dialysis, and four patients (3.1%) needed a permanent pacemaker postoperatively.

Conclusion To our knowledge, this is the first case series to report on a modified implantation technique of the Perceval prosthesis. The Perceval valve prosthesis produces excellent outcome in most pathologies, so that current contraindications should be revised.

Novel Robotic Approach for Minimally Invasive Aortic Heart Valve Surgery

Aortic heart valve replacement is a major surgical intervention, traditionally requiring a large thoracotomy. However, current advances in Minimally Invasive Surgery and Surgical Robotics can offer the possibility to perform the intervention through a narrow mini thoracotomy. The presented surgical robot and proposed surgical scenario aims to provide a highly controllable means for efficiently conducting valve replacement by endoscopic vision. The robot, consisting of a series of joints, is a cable actuated manipulator for reaching the operative site and delivering the valve at the required position. The robot is equipped with endoscopic cameras (to find the hinge points) and three stabilizing flaps (to stabilize the manipulator) for guarantying the proper valve placement. The manipulator is validated by experimental results of flaps' force and camera visions in artificial vessels.