Early results of the Sorin® Perceval S sutureless valve: systematic review and meta-analysis

Rethinking mechanical heart valves in the aortic position: new paradigms in design and testing

Bileaflet mechanical heart valves (MHV) remain a viable option for aortic valve replacement, particularly for younger patients and patients from low- and middle-income countries and underserved communities. Despite their exceptional durability, MHV recipients are at increased risk of thromboembolic complications. As such, the development of the next generation of MHVs must prioritize improved thromboresistance and aim for independence from anticoagulant therapy. However, innovation in MHV design faces several challenges: strict performance and biocompatibility requirements, limited understanding of the mechanisms underlying MHV thrombosis, and a lack of effective testing methodologies to assess how design variations impact both hemodynamic performance and thrombogenicity of MHVs. This paper reviews the emerging paradigms in MHV design, materials and surface modifications that may inspire the development of a new generation of MHVs for aortic valve replacement. We also discuss challenges and opportunities in developing experimental and numerical approaches to achieve a more comprehensive understanding of MHV flow features and the mechanisms of flow-induced blood clotting.

Perceval-S over time. Clinical outcomes after ten years of usage

BACKGROUND

Perceval-S has become a reliable and commonly used option in surgical aortic valve replacement (AVR) since its first implantation in humans 15 years ago. Despite the fact that this aortic valve has been proven efficient enough in the short and mid-term period, there is still lack of evidence for the long-term outcomes.

MATERIALS AND METHODS

This is an observational retrospective study in a high-volume cardiovascular center. Pertinent data were collected for all the patients in whom Perceval-S was implanted from 2013 to 2020.

RESULTS

The total number of patients was 205 with a mean age 76.4 years. Mean survival time was 5.5 years (SE = 0.26). The overall survival probability of patients undergoing aortic valve replacement with Perceval-S at 6 months was 91.0% (Standard Error SE = 2.0%), at one year 88.4% (SE = 2.3%) and at 5-years 64.8% (SE = 4.4%). A detrimental cardiac event leading to death was the probable cause of death in 35 patients (55.6%). The initiation of Transcatheter Aortic Valve Replacement (TAVR) program in our center in 2017 was associated with a decline in the number of very high-risk patients treated with sutureless bioprosthesis. This fact is demonstrated by the significant shift towards lower surgical risk cases, as median Euroscore II was reduced from 5,550 in 2016 to 3,390 in 2020. Mini sternotomy was implemented in 79,5% of cases favoring less invasive approach. Low incidence of reinterventions, patient prosthesis mismatch and structural valve degeneration was detected.

CONCLUSIONS

The survival rate after aortic valve replacement with implantation of Perceval-S is satisfactory in the long-term follow-up. Cases of bioprosthesis dysfunction were limited. Mini sternotomy was used in the majority of cases. TAVR initiation program impacted on the proportion of patients treated with Perceval-S with reduction of high-risk patients submitted to surgery.

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.

Conduction Disorders after Surgical Aortic Valve Replacement Using a Rapid Deployment Aortic Valve Prosthesis: Medium-Term Follow-Up

BACKGROUND

We have previously reported that the incidence of postoperative conduction disorders, especially left bundle branch block (LBBB), after implantation of a rapid deployment Intuity™ Elite aortic valve prosthesis (Edwards Lifesciences, Irvine, CA, USA), was significantly increased compared with conventional aortic valve replacement. We were now interested in how these disorders behaved at intermediate follow-up.

METHODS

All 87 patients who had undergone surgical aortic valve replacement (SAVR) using the rapid deployment Intuity™ Elite prosthesis and were shown to have conduction disorders at the time of hospital discharge were followed up after surgery. These patients' ECGs were recorded at least 1 year after surgery, and the persistence of the new postoperative conduction disorders was assessed.

RESULTS

At hospital discharge, 48.1% of the patients had developed new postoperative conduction disorders, with LBBB being the predominant conduction disturbance (36.5%). At medium-term follow-up (526 days, standard deviation (SD) = 169.6, standard error (SE) = 19.3 days, respectively), 44% of the new LBBB and 50% of the new right bundle branch block (RBBB) had disappeared. There was no new atrio-ventricular block III (AVB III) that occurred. One new pacemaker (PM) was implanted during follow-up because of AVB II Mobitz type II.

CONCLUSIONS

At medium-term follow-up after the implantation of a rapid deployment Intuity™ Elite aortic valve prosthesis, the number of new postoperative conduction disorders, especially LBBB, has considerably decreased but remains high. The incidence of postoperative AV block III remained stable.

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.

Long-term durability of a Perceval aortic valve implanted inside a calcified homograft root in a patient with Klippel-Trenaunay-Weber syndrome

BACKGROUND AND AIMS

Perceval valves are sutureless surgical bioprostheses designed for the aortic position. We report on the use of a Perceval sutureless valve for redo aortic valve replacement inside a heavily calcified homograft root in a patient with Klippel-Trenaunay-Weber syndrome.

MATERIALS AND METHODS

Anonymized patient case data was extracted from hospital electronic records.

RESULTS

A now 62-year-old woman with Klippel-Trenaunay-Weber syndrome underwent homograft aortic root replacement for congenital aortic valve dysplasia when she was 39 years old. She re-presented in 2012 with severe symptomatic aortic regurgitation through the homograft root. Computed tomography scanning revealed a heavily calcified homograft root. In order to avoid a high-risk redo root replacement or a challenging sutured aortic valve replacement, she underwent Perceval sutureless aortic valve implantation. As of 9.5 years following Perceval implantation, the bioprosthetic valve function remains excellent, with no transvalvular regurgitation seen.

DISCUSSION AND CONCLUSION

This case reveals the value of Perceval valve implantation in redo surgery inside a hostile calcified homograft aortic root. Furthermore, we highlight the long-term durability of the Perceval sutureless bioprosthesis.

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.

Short-term outcome of the intuity rapid deployment prosthesis: a systematic review and meta-analysis

OBJECTIVES

Limited access aortic valve replacement is an alternative approach for the treatment of calcified aortic valve disease. To facilitate limited access aortic valve replacement, rapid deployment valve prostheses have been developed aiming to reduce surgical impact. This systematic review gives an overview of current literature regarding the INTUITY or INTUITY Elite rapid deployment biological valve prosthesis.

METHODS

Cochrane, Embase and MEDLINE were searched to identify relevant studies. All studies reporting on patients who underwent isolated or combined surgical aortic valve replacement with the INTUITY or INTUITY Elite valve prosthesis were considered eligible. Primary end points were technical success rate, 30-day mortality, cerebrovascular accident, paravalvular leak and permanent pacemaker implantation. Secondary end points included procedural data such as aortic cross-clamping time, cardiopulmonary bypass time and procedural approach.

RESULTS

A total of 16 articles fulfilled the inclusion and exclusion criteria and comprised 4.184 patients. Thirty-day mortality was 2.7% (1.9-3.7%), cerebrovascular accident 2.6% (1.4-4.7%), permanent pacemaker implantation 7.9% (6.6-9.5%) and severe postoperative paravalvular leak requiring a reintervention 3.3% (1.7-6.1%). Technical success rate varied between 93.9% and 100%. Conventional median sternotomy was most commonly performed, ranging from 21.7% to 89.6%. Upper hemi-sternotomy was performed more often than anterior right thoracotomy, ranging from 10.4% to 63.3% and 2.2% to 26.1%. The mean transvalvular pressure gradient ranged between 9.0 and 10.3 mmHg at 1 year postoperatively.

CONCLUSIONS

This review demonstrates that the technical success rate of the INTUITY or INTUITY Elite rapid deployment valve system is high, also in limited access aortic valve replacement. Mortality and cerebrovascular accident rates are low, but the need for postoperative permanent pacemaker implantation and reintervention rate for paravalvular leakage is increased.

Long-term outcomes of sutureless and rapid-deployment aortic valve replacement: a systematic review and meta-analysis

Background

Sutureless and rapid-deployment aortic valve replacement (SURD-AVR) has become a prominent area of research as the medical community evaluate its place amongst other aortic valve interventions. The main advantages of SURD-AVR established to date are the reduced cross-clamp and cardiopulmonary bypass (CPB) times, as well as facilitating minimally invasive surgery in high-risk surgical patients. This current systematic review and meta-analysis, to our knowledge, is the first focusing on long-term outcomes regarding safety, efficacy and durability of SURD-AVR from available current literature.

Methods

A literature search via six electronic databases was performed from their inception to November 2019. Inclusion criteria for this systematic review included survival and postoperative echocardiographic outcomes greater than five years in patients who underwent SURD-AVR with either Perceval or Intuity valves. Studies were identified and data extracted by two independent reviewers. Long-term survival outcomes were aggregated using digitized Kaplan-Meier curves where available.

Results

After applying predefined inclusion and exclusion criteria, four studies were identified for review. All four studies were observational and in total reported data for 1,998 patients. Almost half (42.4%) of patients underwent SURD-AVR via full sternotomy, with almost one third (30.1%) also undergoing concomitant cardiac procedures. Aggregate overall survival rates at 1-, 2-, 3-, and 5-year follow-up were 94.9%, 91.2%, 89.0%, and 84.2%, respectively. Incidence of strokes (4.8%), severe paravalvular leaks (PVLs) (1.5%) and permanent pacemaker (PPM) insertion (8.2%) at up to 5-year follow-up were acceptable. At 5-year follow-up hemodynamic outcomes were also acceptable for mean pressure gradient (MPG) (range, 8.8-13.6 mmHg), peak pressure gradient (PPG) (range, 18.9-21.1 mmHg) and effective orifice area (EOA) (range, 1.5-1.8 cm²).

Conclusions

Evaluation of the evidence reporting long-term outcomes of SURD-AVR suggests that it is a safe procedure for AVR with low rates of complications. Long-term outcomes presented in this review show that not only does SURD-AVR have acceptable survival rates, but also good hemodynamic performance at 5-year follow-up.

Early Structural Deterioration of a Sutureless Bioprosthetic Aortic Valve

Sutureless bioprosthetic valves such as the Sorin Perceval S valve (SPV) have been used in patients with aortic stenosis that require surgical aortic valve replacement (SAVR). These prostheses have been marketed on the basis of their rapid implantation techniques with avoidance of sutures and reduced aortic cross-clamp times. We report a case of an early failure of a SPV nearly 4 years after implantation in a 58-year-old woman who was low-risk. While the patient’s symptoms initially improved with SAVR with a sutureless bioprosthetic valve, they progressively worsened as the valve degraded, and the leaflets became increasingly calcified and stenotic ultimately, requiring reoperative SAVR with a St. Jude mechanical valve. This case raises the issue of the lack of much-needed data describing the long-term durability and hemodynamic performance of these valves, particularly in a low-risk patient with excellent functional status. We hope to shed further insight into the lack of long-term studies on patients with SPV to assess their longevity and long-term effectiveness, as well as elucidation of possible prevention and monitoring of these potential complications. The use of newer generation prostheses, although attractive for their ease of implantation, potentially carries higher long-term risk due to shorter durability leading to reintervention to address valve deterioration. This is especially true in low-risk patients who are young and active. Cardiology and cardiothoracic surgery societies need to develop a universal registry with follow-up of all valves in order to track and study the durability of these valves, and to evaluate for incidence of known and potential complications.

Mid-term follow-up after suture-less aortic heart valve implantation

Background

Aortic stenosis (AS) is the most common valve disease in the adult population and its prevalence increases with age. Unfortunately, older age and comorbidities significantly increase mortality, operative risk and worsen prognosis. In recent years, sutureless bioprosthesis [sutureless-aortic valve replacement (SU-AVR)] has become an alternative to standard AVR or TAVI in high-risk patients. Compared to standard AVR, the advantages of SU-AVR include shorter valve implantation, shorter aortic cross clamp (ACC) and cardiopulmonary bypass (CPB) times and higher valve EOA with more favorable hemodynamic parameters. Good early clinical and hemodynamic outcomes have been reported in several studies. However, although early SU-AVR results reported in the literature are encouraging, there are few results of long term follow-up. The aim of this study is to present long term echocardiographic hemodynamic outcomes of the Enable sutureless bioprosthesis.

Methods

The first human implantation of the Enable sutureless bioprosthesis was performed on the 13th January, 2005 by the authors of this manuscript. From that time until July 2008, 25 patients underwent isolated SU-AVR implantation. The median preoperative logistic EuroSCORE was 1.92±0.17 [standard deviation (SD)] and the STS score was 2.96±2.73. Preoperatively, 65.4% of patients were in NYHA class III or IV, the peak/mean gradient transaortic gradient was 84.6/52.1 mmHg.

Results

After the SU-AVR procedure, the average peak/mean aortic gradients were respectively: 12.9/7.1 mmHg at the intraoperative time; 18.1/9.5 mmHg at 3-6 months; 18.3/9.6 mmHg at 11-14 months; 16.9/9.3 mmHg at 2 years; 15.3/8 mmHg at 3 years; 13.4/7.1 mmHg at 4 years; 16.7/8.9 mmHg at 5 years follow-up. Other hemodynamic echocardiographic parameters such as LVOT diameter, LVOT peak velocity, LVOT TVI, valve peak velocity and valve TVI were stable during the follow-up period.

Conclusions

In summary, sutureless bioprostheses are safe and effective treatments for valve stenosis with excellent outcomes and hemodynamic profile which remained stable during the follow-up period. The peak and mean gradients were 16.7 and 8.9 mmHg, respectively, over a 5-year follow-up period.

Evaluation of Conduction Disorders after Aortic Valve Replacement with Rapid Deployment Bioprostheses

Objective

The aim of this retrospective, single-center study was to evaluate the occurrence of conduction disorders after rapid deployment aortic bioprosthesis implantation.

Methods

Electrocardiograms of patients undergoing INTUITY (Edwards Lifesciences, Irvine, CA USA) bioprosthesis implantation were collected at admission, during postoperative course, and at discharge. Primary end point was the occurrence of new-onset conduction disorders, defined as complete left bundle branch block, complete right bundle branch block, permanent pacemaker implantation, and worsening of pre-existing rhythm abnormalities. Secondary end points were the assessment of preoperative and postoperative QRS duration and the identification of transitory conduction disorders.

Results

Forty-four patients (July 2015–December 2016) were included in the analysis. Preoperatively, patients with normal conduction and with already existing disorders were 25 (56.8%) and 19 (43.2%), respectively. Primary end point occurred in 14 patients (31.8%). Two patients (4.5%) received pacemaker implantation. In patients with normal preoperative conduction, new abnormalities were found in eight cases (32%): all left bundle branch blocks with one pacemaker implantation. Worsening of pre-existing conduction disorders was found in six patients (31.6%) with one pacemaker implantation. QRS duration increased in 20 patients (45.4%), and average increase was 37 milliseconds. Overall, we observed a significant increase of QRS (96 ± 21 milliseconds vs. 111 ± 28 milliseconds, P < 0.001). Three patients experienced a new-onset temporary left bundle branch block.

Conclusions

New-onset conduction disorders or worsening of pre-existing rhythm abnormalities occur in one third of patients after rapid deployment aortic bioprosthesis implantation. Although the incidence of postoperative pacemaker implantation before discharge is low, strict follow-up is mandatory to identify a potential need for pacemaker implantation in a timely manner.