OBJECTIVES - After a panel process, recommendations on the use of sutureless and rapid deployment valves in aortic valve replacement were given with special respect as an alternative to stented valves.

METHODS - Thirty-one international experts in both sutureless, rapid deployment valves and stented bioprostheses constituted the panel. After a thorough literature review, evidence-based recommendations were rated in a three-step modified Delphi approach by the experts.

RESULTS - Literature research could identify 67 clinical trials, 4 guidelines and 10 systematic reviews for detailed text analysis to obtain a total of 28 recommendations. After rating by the experts, 12 recommendations were identified and degree of consensus for each was determined. Proctoring and education are necessary for the introduction of sutureless valves on an institutional basis as well as for the individual training of surgeons. Sutureless and rapid deployment should be considered as the valve prosthesis of first choice for isolated procedures in patients with comorbidities, old age, delicate aortic wall conditions such as calcified root, porcelain aorta or prior implantation of aortic homograft and stentless valves as well as for concomitant procedures and small aortic roots to reduce cross-clamp time. Intraoperative transoesophageal echocardiography is highly recommended, and in case of right anterior thoracotomy, preoperative computer tomography is strongly recommended. Suitable annular sizes are 19–27 mm. There is a contraindication for bicuspid valves only for Type 0 and for annular abscess or destruction due to infective endocarditis. Careful but complete decalcification of the aortic root is recommended to avoid paravalvular leakage; extensive decalcification should be avoided not to create annular defects. Proximal anastomoses of concomitant coronary artery bypass grafting should be placed during a single aortic cross-clamp period or alternatively with careful side clamping. Available evidence suggests that the use of sutureless and rapid deployment valve is associated with (can translate into) reduced early complications such as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions and renal replacement therapy, respectively, and may result in reduced intensive care unit and hospital stay in comparison with traditional valves.

CONCLUSION - The international experts recommend various benefits of sutureless and rapid deployment technology, which may represent a helpful tool in aortic valve replacement for patients requiring a biological valve. However, further evidence will be needed to reaffirm the benefit of sutureless and rapid deployment valves.

Sutureless, rapid deployment valves and stented bioprosthesis in aortic valve replacement: recommendations of an International Expert Consensus Panel.

OBJECTIVES: The aim of this study was to analyse early postoperative outcomes and 2-year survival after aortic valve replacement (AVR) through a ministernotomy with a sutureless bioprosthesis implantation compared with a full sternotomy with implantation of a stented bioprosthesis. METHODS: Patients who underwent primary isolated non-emergent AVR at six European centres were included in the study. Of these, 182 (32%) underwent a ministernotomy with a sutureless bioprosthesis (ministernotomy sutureless group) and 383 (68%) a full sternotomy with a stented bioprosthesis (full sternotomy stented group). Propensity score matching was used to reduce selection bias. RESULTS: In the overall cohort, 30-day mortality was 1.6 and 2.1%, and 2-year survival was 92 and 92% in the ministernotomy sutureless group and in the full sternotomy stented group, respectively. Propensity score matching resulted in 171 pairs with similar characteristics and operative risk. Aortic cross-clamp (40 vs 65 min, P< 0.001) and cardiopulmonary bypass time (69 vs 87 min, P< 0.001) were shorter in the ministernotomy sutureless group. Patients undergoing ministernotomy received less packed red blood cells but the risk for postoperative permanent pacemaker implantation was higher. There were no differences regarding 30-day mortality or 2-year survival between the two groups. CONCLUSIONS: AVR through a ministernotomy with implantation of a sutureless bioprosthesis was associated with shorter aortic crossclamp and cardiopulmonary bypass time and less transfusion of packed red blood cells, but a higher risk for postoperative permanent pacemaker implantation compared with a full sternotomy with a stented bioprosthesis.

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Aortic valve replacement through full sternotomy with a stented bioprosthesis versus minimally invasive sternotomy with a sutureless bioprosthesis.

A comparison of conventional surgery, transcatheter aortic valve replacement, and sutureless valves in "real-world" patients with aortic stenosis and intermediate- to high-risk profile.

OBJECTIVES

The Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry (SURD-IR) was established by a consortium of 18 research centres-the International Valvular Surgery Study Group (IVSSG)-to overcome limitations of the literature and provide adequately powered evidence on sutureless and rapid-deployment aortic valves replacement (SURD-AVR).

METHODS

Data from 3343 patients undergoing SURD-AVR over a 10-year period (2007-2017) were collected in the registry. The mean age of the patients was 76.8 ± 6.7 years, with 36.4% being 80 years or older. The average logistic EuroSCORE was 11.3 ± 9.7%.

RESULTS

Isolated SURD-AVR was performed in 70.7% (n = 2362) of patients using full sternotomy (35.3%) or less invasive approaches (64.8%). Overall hospital mortality was 2.1%, being 1.4% in patients who had isolated SURD-AVR and 3.5% in those who had concomitant procedures (P < 0.001). When considering baseline risk profile, mortality rate was 0.8% and 1.9% in low risk (logistic EuroSCORE <10%) isolated SURD-AVR and combined SURD-AVR, respectively, and 2.2% and 3.7% in higher risk patients (logistic EuroSCORE ≥10%). Postoperative neurological complications included stroke (2.8%) and transient ischaemic attack (1.1%). New atrioventricular block requiring pacemaker occurred in 10.4% of the patients. The rate of pacemaker implantation significantly decreased over time [from 17.2% (2007-2008) to 5.4% (2016); P = 0.02].

CONCLUSIONS

Our findings showed that SURD-AVR is a safe and effective alternative to conventional aortic valve replacement and is associated with excellent clinical outcomes. Further adequately powered statistical analyses from the retrospective and prospective SURD-IR will allow for the development of high-quality evidence-based clinical guidelines for SURD-AVR.

Sutureless and Rapid-Deployment Aortic Valve Replacement International Registry (SURD-IR): early results from 3343 patients

Surgical sutureless and interventional transcatheter aortic valve prostheses are nowadays extensively adopted in high-risk elderly patients. An explorative analysis was carried out to compare the clinical outcome and costs associated to these approaches. Since 2010, a total of 626 patients were distributed between transcatheter aortic valve implantation (TAVI; n = 364) and sutureless (n = 262) groups. Patients of both groups were not comparable for clinical and surgical characteristics, but many patients were in a "gray zone"; therefore, a retrospective propensity score analysis was possible and performed. For the matched pair samples, postoperative, follow-up clinical data, and costs data were obtained. In-hospital death occurred in 5 patients in sutureless group and 3 patients in TAVI group (p = 0.36). Blood transfusions were higher in sutureless group (2.1 ± 2.3 vs 0.4 ± 1.0 U). TAVI group had a shorter intensive care unit and hospital stay (2.2 ± 2.7 vs 3.2 ± 3.5 days, p = 0.037; 12 ± 6 vs 14 ± 6 days, p = 0.017). No differences in postoperative neurologic (p = 0.361), renal (p = 0.106), or respiratory (p = 0.391) complications were observed between groups. At follow-up (24.5 ± 13.8 months), 1 patient in sutureless group and 7 patients in TAVI group died (p = 0.032). Paravalvular leakage occurred more frequently in patients in TAVI group (35 [34%] vs 7 [6.9%]; p <0.001) with an impact on follow-up survival rate. The costs associated to the 2 procedures are similar when the cost of the device was excluded (p = 0.217). When included, the sutureless approach resulted a cost saving (€22,451 vs €33,877, p <0.001). In conclusion, the patients in the "gray zone" record a satisfying clinical outcome after sutureless surgery and TAVI. Patients in the sutureless group endure more hospital complications, but TAVI entails a higher follow-up mortality. On the costs aspects, TAVI technologies are more expensive, and it reflects on higher overall hospital costs.

Clinical Outcome and Cost Analysis of Sutureless Versus Transcatheter Aortic Valve Implantation With Propensity Score Matching Analysis.

http://lib.ajaums.ac.ir/booklist/1-s2.0-S0003497514008583-main.pdf

Better short-term outcome by using sutureless valves: a propensity-matched score analysis.

Despite advances in surgical techniques for mitral valve repair, more than 20% of patients require reoperation within 10 years due to recurrence of severe mitral regurgitation. However, reoperations on the mitral valve are often associated with increased morbidity and mortality. We report a transapical mitral valve-in-ring implantation in a patient who had undergone mitral valve repair for ischemic mitral regurgitation using a complete semi-rigid Memo 3D mitral ring (LivaNova Group, Milan, Italy).

Transapical transcatheter valve-in-ring implantation following mitral annuloplasty.

Single-use, closed incision management (CIM) systems offer a practical means of delivering negative pressure wound therapy to patients. This prospective study evaluates the Prevena™ Therapy system in a cohort of coronary patients at high risk of deep sternal wound infection (DSWI). Fifty-three consecutive patients undergoing bilateral internal thoracic artery (BITA) grafting were preoperatively elected for CIM with the Prevena™ Therapy system, which was applied immediately after surgery. The actual rate of DSWI in these patients was compared with the expected risk of DSWI according to two scoring systems specifically created to predict either DSWI after BITA grafting (Gatti score) or major infections after cardiac surgery (Fowler score). The actual rate of DSWI was lower than the expected risk of DSWI by the Gatti score (3.8 vs. 5.8%, p = 0.047) but higher than by the Fowler score (2.3%, p = 0.069). However, while the Gatti score showed very good calibration (χ2 = 4.8, p = 0.69) and discriminatory power (area under the receiver-operating characteristic curve 0.838), the Fowler score showed discrete calibration (χ2 = 10.5, p = 0.23) and low discriminatory power (area under the receiver-operating characteristic curve 0.608). Single-use CIM systems appear to be useful to reduce the risk of DSWI after BITA grafting. More studies have to be performed to make stronger this finding.

Management of closed sternal incision after bilateral internal thoracic artery grafting with a single-use negative pressure system

Background The Freedom SOLO (FS) stentless bovine-pericardial prosthesis with a supra-annular implantation technique can be a viable option for patients with endocarditic annular destruction We assessed early- and long-term outcomes following the use of this prosthesis in extensive aortic valve endocarditis Methods From 2006 to 2016, 59 patients with extensive aortic endocarditis underwent aortic valve replacement (AVR) with FS (cumulative follow-up 263 patients-years) in three European centers; all patients presented annular tissue infection, while 543% of patients had annular abscess Results Mean age was 66 ± 11 years and mean EuroSCORE I was 303% (standard deviation: 241%) In our series, 305% of patients had prosthetic valve endocarditis Early mortality was 152% (nine patients) Estimated overall survival at 5 and 10 years was 689% (95% confidence interval [CI]: 628–750%) and 591% (95% CI: 668–812%), respectively At 10-year survival, freedom from valve-related death was 837% (95% CI: 809–865%) No structural valve deterioration was reported in this series Five patients (85%) had recurrent endocarditis during follow-up and two of them underwent reoperation Survival freedom from reoperation and endocarditis at 10-year follow-up was 880% (CI: 804–956%) and 867% (CI: 805–929%), respectively Conclusion FS stentless bioprosthesis is a valuable and simple option to achieve AVR in patients with extensive aortic annulus endocarditis Although in this group of complex patients, early mortality remains considerably high, late survival outcomes are comparable to the more technically demanding homografts and conventional stentless bioprostheses, with low rates of endocarditis recurrence

Laszlo Gazdag

Papers

Better short-term outcome by using sutureless valves: a propensity-matched score analysis.

Transapical transcatheter valve-in-ring implantation following mitral annuloplasty.

Management of closed sternal incision after bilateral internal thoracic artery grafting with a single-use negative pressure system

Is the Freedom SOLO Stentless Bioprosthesis a Useful Tool for Patients with Aortic Endocarditis and Aortic Annular Destruction

Randomized Study for Mammary Artery Harvesting: Please, Also Consider Wound Management!