Sutureless Aortic Prosthesis Valves versus Transcatheter Aortic Valve Implantation in Intermediate Risk Patients with Severe Aortic Stenosis: A Literature Review

Aortic stenosis remains the most frequently occurring valvular pathology in the elderly population of Western countries. According to the latest guidelines, the therapeutic choice of aortic stenosis depends on the age of the patient (<75 years or >75 years) and the risk class (STS-Prom/Euroscore II < o >4%). Therefore, if the surgical indication is clear in young and low-risk patients and percutaneous treatment is the gold standard in older and high-risk patients, the therapeutic choice is still debated in intermediate-risk patients. In this group of patients, aortic valve stenosis treatment depends on the patient's global evaluation, the experience of the center, and, no less importantly, the patient's will. Two main therapeutic options are debated: surgical aortic valve replacement with sutureless prosthesis versus transcatheter aortic valve implantation. In addition, the progressive development of mininvasive techniques for aortic valve surgery (right-anterior minithoracotomy) has also reduced the peri- and post-operative risk in this group of patients. The purpose of this review is to compare sutureless aortic valve replacement (SuAVR) versus TAVI in intermediate-risk patients with severe aortic stenosis.

Percutaneous versus surgical approach to aortic valve replacement with coronary revascularization: A systematic review andmeta-analysis

OBJECTIVE

The optimal treatment of patients with severe aortic stenosis (AS) and complex coronary artery disease (CAD) remains controversial. We conducted a meta-analysis to investigate outcomes of transcatheter aortic valve replacement (TAVR) with percutaneous coronary intervention (PCI) versus surgical aortic valve replacement (SAVR) with coronary artery bypass grafting (CABG).

METHODS

We searched PubMed, Embase, and Cochrane databases from its inception up to 17 December 2022 for studies that assessed TAVR + PCI versus SAVR + CABG in patients with AS and CAD. The primary outcome was perioperative mortality.

RESULTS

Six observational studies including 135,003 patients assessing TAVI + PCI (n = 6988) versus SAVR + CABG (n = 128,015) were included. Compared to SAVR + CABG, TAVR + PCI was not significantly associated with perioperative mortality (RR, 0.76; 95% CI, 0.48-1.21; p = 0.25), vascular complications (RR, 1.85; 95% CI, 0.72-4.71; p = 0.20), acute kidney injury (RR, 0.99; 95% CI, 0.73-1.33; p = 0.95), myocardial infraction (RR, 0.73; 95% CI, 0.30-1.77; p = 0.49), or stroke (RR, 0.87; 95% CI, 0.74-1.02; p = 0.09). TAVR + PCI significantly reduced the incidence of major bleeding (RR, 0.29; 95% CI, 0.24-0.36; p < 0.01) and length of hospital stay (MD, -1.60; 95% CI, -2.45 to -0.76; p < 0.01), but increased the incidence of pacemaker implantation (RR, 2.03; 95% CI, 1.88-2.19; p < 0.01). At follow-up, TAVR + PCI was significantly associated with coronary reintervention (RR, 3.17; 95% CI, 1.03-9.71; p = 0.04) and a reduced rate of long-term survival (RR, 0.86; 95% CI, 0.79-0.94; p < 0.01).

CONCLUSIONS

In patients with AS and CAD, TAVR + PCI did not increase perioperative mortality, but increased the rates of coronary reintervention and long-term mortality.

Sutureless Valves, a "Wireless" Option for Patients With Aortic Valve Disease: JACC State-of-the-Art Review

Transcatheter technologies triggered the recent revision of the guidelines that progressively widened the indications for the treatment of aortic stenosis. On the surgical realm, a technology avoiding the need for sutures to anchor the prosthesis to the aortic annulus has been developed with the aim to reduce the duration of cardiopulmonary bypass and simplify the process of valve implantation. In addition to a transcatheter aortic valve replacement (TAVR)-like stent that exerts a radial force, these so-called "rapid deployment valves" or "sutureless valves" for aortic valve replacement also have cuffs to improve sealing and reduce the risk of paravalvular leak. Despite promising, the actual advantage of sutureless valves over traditional surgical procedures (surgical aortic valve replacement) or TAVR is still debated. This review summarizes the current comparative evidence reporting outcomes of "sutureless valves" for aortic valve replacement to TAVR and surgical aortic valve replacement in the treatment of aortic valve stenosis.

Early outcomes of aortic valve replacement with Perceval PLUS sutureless valve: results of the prospective multicentric MANTRA study

BACKGROUND

The aim of this study is to report the preliminary real-word clinical and hemodynamic performance from the MANTRA study in patients undergoing aortic valve replacement with Perceval PLUS sutureless valve.

METHODS

MANTRA is an ongoing "umbrella" prospective, multi-center, international post-market study to collect real-life safety and performance data on Corcym devices (Corcym S.r.l, Saluggia, Italy). Clinical and echocardiographic outcomes were collected preoperatively, at discharge and at each follow up. KCCQ-12 and EQ-5D-5L quality of life questionnaires were collected preoperatively and at 30-days.

RESULTS

A total of 328 patients underwent aortic valve replacement with Perceval PLUS in 29 International institutions. Patients were enrolled from July 2021 to October 2023 and enrollment is still ongoing. Mean age was 71.9 ± 6.4 years, mean EuroSCORE II was 2.9 ± 3.9. Minimally invasive approach was performed in 44.2% (145/328) of patients; concomitant procedures were done in 40.8% (134/328) of cases. Thirty-day mortality was 1.8% (6/328) and no re-interventions were reported. Pacemaker implant was required in 4.0% (13/328) of the patients. The assessment of the functional status demonstrated marked and stable improvement in NYHA class in most patients at 30-day follow-up, with significant increase of KCCQ-12 summary score (from 58.8 ± 23.0 to 71.8 ± 22.1, p < 0.0001) and EQ-5D-5L VAS score (from 64.5 ± 20.4 to 72.6 ± 17.5, p < 0.0001). Mean pressure gradient decreased from 46.2 ± 17.3 mmHg to 10.1 ± 4.7 mmHg at 30-day follow-up. Low or no incidence of moderate-to-severe paravalvular or central leak was reported.

CONCLUSIONS

Preliminary results demonstrate good clinical outcomes and significant improvement of Quality of Life at 30-days, excellent early hemodynamic performance within patient implanted with Perceval PLUS.

TRIAL REGISTRATION

The MANTRA study has been registered in ClinicalTrials.gov (NCT05002543, Initial release 26 July 2021).

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.

Predictors of New and Persistent New Left Bundle Branch Block One Year after the Implantation of a Sutureless and Rapid-Deployment Aortic Valve Prosthesis

INTRODUCTION

Conduction disorders following aortic valve replacement therapy (AVR), either surgical or percutaneous, are related to a higher risk of complete atrioventricular block and permanent pacemaker implantation (PPI).

AIM

The objective of this study was to assess risk factors regarding the incidence of new postoperative and persistent new left bundle branch block (LBBB) 1 year after the implantation of a sutureless/rapid-deployment (SURD) aortic valve prosthesis.

MATERIAL AND METHODS

The current study included 200 consecutive patients treated with isolated or concomitant AVR between May 2014 and May 2017 at the Department of Cardiac Surgery in Pasawa with SURD aortic valve EDWARDS INTUITY EliteTM implantation. The patients were divided according to the presence of new postoperative LBBB (67 patients, 33.5%) and persistent new LBBB 1 year after AVR (35 patients, 17.5%). A comparative analysis was performed between patients with and without new LBBB after AVR and those with and without persistent LBBB 1 year after AVR. Univariate and multivariate regression analyses were conducted to extract the risk factors of LBBB occurrence.

RESULTS

Among the risk factors for the lack of new LBBB development after AVR, Euroscore II (p < 0.001) was found, while for the occurrence of persistent new LBBB 1 year after AVR, atrial fibrillation (p = 0.001), length of hospital stay (p = 0.001) and body mass index (p = 0.004) were noted.

CONCLUSIONS

Patients with new or persistent new LBBB 1 year after AVR had lower mean Euroscore II and BMI values. Their stay at the hospital was also shorter.

Incidence, Predictors and Prognostic Value of Permanent Pacemaker Implantation Following Sutureless Valve Implantation in Low-Risk Aortic Stenosis Patients

OBJECTIVES

SU-SAVR has been associated with higher rates of permanent pacemaker (PPM) compared with conventionally implanted aortic bioprostheses. The purpose of this study was to determine the incidence, predictors and mid-term prognostic impact of PPM after Perceval (Livanova, London, UK) SU-SAVR in low-risk patients.

METHODS

A total of 400 consecutive low-risk (EuroSCORE II < 4%) patients without prior pacemaker who underwent SAVR with the Perceval prosthesis from 2013 to 2019 in two centres were included. Baseline, clinical and electrocardiographic parameters, procedural characteristics, and follow-up data were collected.

RESULTS

PPM was required in 36 (9%) patients after SU-SAVR, with a median time between the procedure and PPM implantation of 7.5 (4.5-10.5) days. Older age and prior right bundle branch block (RBBB) were associated with an increased risk of PPM (p < 0.05 for all), but only baseline RBBB was found to be an independent predictor of new PPM requirement (Odds ratio: 2.60, 95% confidence interval: 1.15-5.81; p = 0.022). At a median follow-up of 3.4 (2.3-4.5) years, there were no differences between groups in mortality (PPM: 36%, no PPM: 22%, p = 0.105) or heart failure rehospitalization (PPM: 25%, no PPM: 21%, p = 0.839).

CONCLUSIONS

About 1 out of 10 low-risk patients with aortic stenosis undergoing SU-SAVR with the Perceval prosthesis required PPM implantation. Prior RBBB determined an increased risk (close to 3 times) of PPM following the procedure. PPM was not associated with a higher risk of clinical events at 3-year follow-up.