Non-Inferiority of Sutureless Aortic Valve Replacement in the TAVR Era: David versus Goliath

Abstract

Background: The rapid development of transcatheter treatment methods has made transcatheter aortic valve replacement (TAVR) a feasible alternative to conventional surgical aortic valve replacement (SAVR). Recently, indications for TAVR have been expanded to intermediate- and low-risk patients, although there still remains a portion of ineligible patients. We sought to evaluate and compare our experience with sutureless SAVR and transapical TAVR in the “grey-area” of patients unsuitable for transfemoral access. Methods: Between April 2018 and June 2021, 248 consecutive patients underwent a sutureless SAVR (SU-SAVR) or TA-TAVR at our institution. We performed a pair-matched analysis and identified 56 patient pairs based on the EuroSCORE II. All transcatheter procedures were performed using SAPIEN XT/3™ prostheses, while all surgical procedures deployed the Perceval (LivaNova) aortic valve. Results: All patients presented with multiple comorbidities as reflected by the median EuroSCORE-II of 3.1% (IQR 1.9–5.3). Thirty-four patients from the surgical group (60.7%) underwent a concomitant myocardial revascularization. There was no significant difference in major adverse events, pacemaker implantation or postoperative mortality during follow-up. Both interventions demonstrated technical success with similar mean postoperative pressure gradients at follow-up and no cases of paravalvular leakage. Conclusions: Sutureless aortic valve replacement constitutes a feasible treatment alternative for patients with aortic valve disease who are ineligible for transfemoral access route and/or require concomitant coronary revascularization. With its excellent hemodynamic performance, similar survival compared to TA-TAVR, and high cost-efficiency without compromising the postoperative outcomes and in-hospital length of stay SU-AVR might be considered for patients in the “grey-area” between TAVR and SAVR.

Single-Center Real-World Experience with Sutureless Aortic Valve Prosthesis in Isolated and Combined Procedures

“…The growing population of elderly patients suffering from aortic valve disease highlights the importance of implementing minimally invasive techniques that can reduce ischemia reperfusion injury during aortic valve replacement [ 5 ]. In this regard, SU-AVR and TAVI are both considered promising and less invasive approaches for these patients [ 6 , 7 , 8 ]. Although the use of TAVI in the lower-risk patients is increasingly supported by evidence in the literature [ 29 ], most of the studies which compare TAVI with the standard surgical AVR do not include patients who underwent an SU-AVR.…”

“…In all cases, Perceval prosthesis was implanted using the ‘snugger method’, as previously described [ 24 ]. Concomitant procedures were combined with SU-AVR and performed as described in our recent research [ 7 , 11 , 25 , 26 , 27 ].…”

“…To mitigate the risk of ischemia reperfusion injury during valve procedures, efforts are underway to reduce ECC and aortic CC time. Amongst the new approaches, sutureless aortic valve replacement (SU-AVR) and transcatheter aortic valve implantation (TAVI) are considered less invasive, alternative approaches for aortic valve patients [ 6 , 7 , 8 ].…”

Early and Long-Term Clinical and Echocardiographic Outcomes of Sutureless vs. Sutured Bioprosthesis for Aortic Valve Replacement

“…Studies were excluded if any of the following criteria were met: (1) reported outcomes of exclusively other SU-AVR [11][12][13][14][15]; (2) grouped outcomes of Perceval with other prostheses in the same cohort [16][17][18][19]; (3) not published in the English language; (4) not published in a peer-reviewed journal; (5) was a conference abstract [20][21][22][23]; and (6) case reports.…”