History, development and clinical perspectives of sutureless and rapid deployment surgical aortic valve replacement

Acurate Neo2 for valve-in-valve treatment of degenerated 3F Enable sutureless bioprosthetic valve in nonagenarian patient: a case report

Background

Sutureless bioprosthetic valves (SBVs) are engineered to enable a less invasive surgical valve replacement procedure in patients at high surgical risk. Valve degeneration is a relatively common occurrence across all types of surgical valves, including SBVs. Valve-in-valve (ViV) procedures are increasingly becoming the preferred treatment for many cases of valve degeneration due to their minimally invasive nature and favourable long-term outcomes. However, the specific structural characteristics of SBVs present challenges for ViV procedures, and the evidence on this subject remains limited.

Case summary

A 91-year-old man was admitted to our hospital presenting with dyspnoea due to severe aortic regurgitation in a degenerated 3F Enable sutureless valve. Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) was successfully performed using a self-expanding Acurate Neo2 valve, yielding good haemodynamic results without overt interaction between the prosthesis. A 6-month follow-up echocardiogram confirmed excellent valve performance.

Discussion

ViV-TAVI is a well-established treatment for bioprosthetic valve failure in high-risk patients. However, sutureless valve degeneration presents a challenging scenario for ViV procedures, with only a limited number of cases performed using the Acurate platform. In this case, we demonstrated the technical feasibility of ViV using the Acurate system in a less explored surgical sutureless bioprosthesis.

A rapid deployment valve option for failing Medtronic Freestyle full root: a single centre experience

BACKGROUND

There are several high-risk treatment options for valve failure of a biological full root replacement. When tailoring the best treatment option for the patient, implantation of a rapid deployment valve (RDV) should be considered.

CASE PRESENTATION

Six patients presented with aortic regurgitation in a full root Freestyle bioprosthesis. Three had a history of valve endocarditis, while the remaining had non-infectious structural valve deterioration with leaflet and commissural tears. All patients were treated with a rapid deployment EDWARDS INTUITY Elite valve. Follow-up was complete for all patients. Postoperative echocardiography showed well-functioning valve prostheses with no paravalvular leaks and acceptable pressure gradients. Echocardiographic follow-up demonstrated excellent pressure gradients and a considerable decrease in the left ventricular mass index and left ventricular end-diastolic dimensions. Follow-up cardiac CT showed no signs of coronary obstruction or other pathology. During a median follow-up of 30 months neither biological valve failure, nor any events within the composite endpoint of major adverse cardiac and cerebrovascular events occurred.

CONCLUSIONS

This case series presents the EDWARDS INTUITY valve as a good treatment option in patients with failing Freestyle roots.

Lactate Dehydrogenase Levels after Aortic Valve Replacement: What Do They Tell Us?

INTRODUCTION

 Lactate dehydrogenase (LDH) is a standard postoperative marker for hemolysis in the presence of paravalvular leakage (PVL) after replacement of the aortic valve (AVR). LDH is elevated in certain valves by a fluttering phenomenon. Previous studies suggested a correlation between microparticles (MPs) and LDH elevation after AVR. Thus, we analyze the postoperative relevance of LDH after AVR with transapical transcatheter aortic valves (TA-TAVs) or rapid deployment valves (RDVs).

METHODS

 We retrospectively analyzed the data from patients who received an AVR with the RDV and TA-TAV groups between 2015 and 2018. We compared PVL and LDH levels before and after surgery, transvalvular gradients, heart block that required pacemaker implantation, and 30-day mortality.

RESULTS

 In total, 138 consecutive patients were selected for the study: 79 patients in the RDV group (37 Sorin Perceval valve, 42 Edwards Intuity valve) and 59 in the TA-TAV group (Edwards Sapien valve). TA-TAV group was older (median 10 years) and had a higher incidence of PVL (odds ratio 11, 95% confidence interval [CI] 2.5-73.2, p = 0.04)). Interestingly, the TA-TAV group showed lower levels of LDH despite higher rates of PVL. Of note, the Perceval valve trended toward higher LDH values. Additionally, the RDV group showed an increased arrhythmia profile (p = 0.0041); however, the results show lower incidence in pacemaker implantation (95% CI 0.05-1.65, p = 0.635). The 30-day mortality was similar between groups.

CONCLUSION

 Our data do not support the association between hemolysis and PVL despite elevated LDH in suture-free valves. Our results suggest that LDH could be a marker of extreme heart muscle output or fluttering phenomenon and not a marker of hemolysis after sutureless AVR.

Sutureless vs. rapid-deployment valve: a systemic review and meta-analysis for a direct comparison of intraoperative performance and clinical outcomes

Background

Sutureless and rapid-deployment valves are bioprostheses anchoring within the aortic annulus with few sutures, and they act as a hybrid of conventional surgical and transcatheter valves under aortic valve replacement. Considering that the 3F Enable valve is now off-market, the only two sutureless and rapid-deployment valves available on the world marketplace are the Perceval and Intuity valves. However, a direct comparison of the function of these two valves eludes researchers.

Purpose

Against this background, we performed this systematic review and meta-analysis comparing the intraoperative performance and early clinical outcomes between the Perceval valve and the Intuity valve under sutureless and rapid-deployment aortic valve replacement.

Methods

We systematically searched electronic databases through PubMed/MEDLINE, OvidWeb, Web of Science, and Cochrane Central Register of Controlled Trials (from the establishment of the database to November 17, 2022, without language restriction) for studies comparing the sutureless valve (the Perceval) and the rapid-deployment valve (the Intuity) under aortic valve replacement. Our primary outcomes were early mortality and postoperative transvalvular pressure gradients. The secondary outcomes were defined to include aortic cross-clamp and cardiopulmonary bypass time, paravalvular leak (any paravalvular leak, moderate-to-severe paravalvular leak) after aortic valve replacement, need for pacemaker implantation, postoperative neurological events (stroke), and intensive care unit stay.

Results

This meta-analysis included ten non-randomized trials with 3,526 patients enrolled (sutureless group = 1,772 and rapid-deployment group = 1,754). Quality assessments were performed, with the mean scores of the studies reading 6.90 (SD = 0.99) out of 9 according to the Newcastle-Ottawa Scale. Compared with rapid-deployment aortic valve replacement, sutureless aortic valve replacement was associated with higher mean and peak transvalvular pressure gradients postoperatively. In contrast, aortic cross-clamp and cardiopulmonary time were needed less in sutureless aortic valve replacement vs. rapid-deployment aortic valve replacement. There was no evidence of significant publication bias observed by the funnel plot and Egger's test.

Conclusions

For postoperative hemodynamics, sutureless aortic valve replacement was associated with increased mean and peak transvalvular pressure gradients compared with rapid-deployment aortic valve replacement. In sharp contrast, sutureless aortic valve replacement significantly reduced the amount of time needed for fixing the aortic cross-clamp and the cardiopulmonary bypass procedure.

Systematic Review Registration

https://www.crd.york.ac.uk/prospero/, identifier CRD42022343884.

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.

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.

Updates on the Latest Surgical Approach of the Aortic Stenosis

Over the last twenty years, we marked significant progresses in the field of tissue engineering and the development of new aortic valve structural and delivery systems. These continuous iterations on the field, have completely changed the surgical indications and approaches for AVR. Nowadays, therapeutic decisions are endorsed by international guidelines; however, new technical advances need a new integrated approach. The clinical scenarios issued from the interaction between the Guidelines and the newest approaches and technologies are regularly on debate by the Heart Team. We will present some of our most encountered situations and the pattern of our therapeutic decisions. To easily navigate through Guidelines and clinical scenarios, we reported in this review a simplified and easy to use Clinical decision-making algorithm that may be a valuable tool in our daily practice.