Clinical outcomes after implantation of a sutureless aortic bioprosthesis with concomitant mitral valve surgery: the SURE-AVR registry

Mitral Valve Repair Versus Replacement in Patients Undergoing Concomitant Aortic Valve Replacement

AIM

Mitral valve repair (MVr) is associated with more favourable long-term outcomes than mitral valve replacement (MVR) in cases of isolated mitral valve disease suitable for repair. However, there is debate regarding whether the superiority of MVr extends to patients with concomitant aortic and mitral valve disease. Therefore, this meta-analysis was conducted to compare the survival benefits between aortic valve replacement (AVR) plus MVr with a double valve replacement (DVR).

METHOD

A comprehensive literature search was conducted on PubMed, EMBASE, and Cochrane until 20 October 2022. Studies comparing MVr and MVR in patients undergoing concomitant AVR were included. The primary outcome was long-term survival. The secondary outcomes were early mortality, mitral valve reoperation, and valve-related adverse events.

RESULTS

Sixteen studies with a total of 140,638 patients were included in this analysis. Patients undergoing AVR plus MVr exhibited a favourable trend in long-term survival (HR 0.85; 95% CI 0.71-1.03; p=0.10; I2=58%). The reconstructed Kaplan-Meier curve revealed that the long-term survival at 5, 10, and 15 years was higher in the AVR plus MVr (80.95%, 67.63%, and 51.18%, respectively) than in the DVR group (76.62%, 61.36%, 43.21%, respectively). Aortic valve replacement plus MVr had a lower risk of early mortality (RR 0.67; 95% CI 0.58-0.79; p<0.001; I2=77%), thromboembolic events (RR 0.81; 95% CI 0.67-0.98; p=0.03; I2=5%), and haemorrhagic events (RR 0.87; 95% CI 0.78-0.98; p=0.01; I2=59%). Moreover, both groups displayed comparable rates of mitral valve reoperation (HR 1.73; 95% CI 0.86-3.48; p=0.13; I2=60%) and infective endocarditis (RR 1.60; 95% CI 0.65-3.93; p=0.31; I2=0%). However, the rate of reoperation for AVR plus MVr significantly increased in rheumatic heart disease patients (HR 3.30, 95% CI 1.66-6.59; p<0.0001).

CONCLUSIONS

Compared with DVR, AVR plus MVr was associated with favourable long-term survival, reduced early mortality risk, and a lower incidence of thromboembolic and haemorrhagic events without increasing the risk of mitral valve reoperation or infective endocarditis in unselected patients. However, higher reoperation rates were observed in rheumatic heart disease patients undergoing AVR plus MVr.

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.

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 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.