Sutureless aortic valve replacement in high-risk patients with active infective endocarditis

Abstract

Background: Surgical aortic valve replacement remains the gold standard of treatment in patients with active infective endocarditis. Such procedures tend to carry a significantly higher operative risk when compared to the conventional aortic valve replacement for a non-infective aortic valve disease. Sutureless aortic valve replacement (SU-AVR) has been introduced into cardiac surgery to allow for a simpler implementation of minimally invasive procedures. Although SU-AVR in several extended indications has proven to be successful, the data on the implementation of SU-AVR in patients with infective aortic valve endocarditis remain scarce. The aim of the study was to examine the feasibility of SU-AVR in high-risk patients with active infective aortic valve endocarditis.Methods: Between December 2019 and March 2022, a total of 151 consecutive patients underwent a SU-AVR for various indications at our institution. Of those, in 13 consecutive high-risk patients SU-AVR was indicated because of infective aortic valve endocarditis. In all cases Perceval S aortic valve prosthesis (Corcym, Saluggia, Italy) was used and the implantation has been performed with Snugger-method.Results: The mean age of the patients at operation was 74.05±11.6 years. Eight of the patients suffered from prosthesis endocarditis while the other five patients presented with the endocarditis of the native aortic valve. All patients suffered from multiple comorbidities, as reflected by a mean logistic EuroSCORE of 47.9%±23.1% and EuroSCORE II of 28.7%±22.0%. In 8 patients (61.5%) a concomitant procedure was necessary. Also 8 patients (61.5%) underwent a redo procedure. Bypass-and cross-clamp (CC) times were 89.8±33.6 and 59.1±27.8 minutes, respectively. We observed no paravalvular leakage and no cases of left-ventricular outflow tract obstruction. Postoperative mean gradients after SU-AVR implantation were 8.1±4.8 mmHg.Conclusions: SU-AVR in patients presenting with active infective endocarditis is a safe and feasible surgical alternative to the conventional operation. Clearly, this operative approach should be considered particularly for high-risk patients in whom successful operative outcomes are determined by a reduction in bypass-and CC time. SU-AVR provides excellent hemodynamic performance with a low risk of paravalvular leakage and low transvalvular gradients, whilst simplifying the surgical procedure.

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“…Similarly, in the previously cited recent study by Zubarevich et al [7], the authors reported in their series of 13 patients a mean CPB and AXC times of 89.8±33.6 minutes and of 59.1±27.8 minutes, respectively. Not only many of the patients with IE are too sick to sustain long morbid operations, but also these patients would probably benefit the most from a hemodynamically good postoperative valvular performance and a low rate of PVL.…”

“…Even in this appalling scenario, our observed 30-d mortality was 13.9% and the 1-year survival exceeded the 72%. Recently, Zubarevich et al [7] have published a series 13 patients undergoing SU-AVR because of a complicated aortic IE. In that study, the authors reported a 30-d mortality of 23.1%, yet the expected mortality estimated by the logistic EuroSCORE I and EuroSCORE II was 47.9%±23.1% and 28.7%±22.0%, respectively.…”

The Perceval Sutureless Bioprosthetic Aortic Valve: Evolution of Surgical Valve Technology

“…Both Weymann et al and Zubarevich et al have described their experience with Perceval S use in 9 and 13 patients with IE, respectively. 54 , 55 Early postoperative results have been promising, with low mortality, no required PPI, and satisfactory valve hemodynamics upon discharge. However, 3-month and 6-month mortality rates of 23.1% and 46.2%, respectively, do raise some concerns, but it is important to note that these were very high-risk patients, with the majority having a history of previous cardiac surgery and requiring concomitant procedures.…”

“…However, 3-month and 6-month mortality rates of 23.1% and 46.2%, respectively, do raise some concerns, but it is important to note that these were very high-risk patients, with the majority having a history of previous cardiac surgery and requiring concomitant procedures. 54 SUAVR in patients with IE appears feasible; however, much more investigation is ultimately required prior to the more widespread adoption of this practice.…”

Sutureless aortic valve replacement in patients with active infective endocarditis: is it contraindicated or recommended?

“…The latter could hypothetically contribute to its’ lower susceptibility to infectious processes ”. Based on this hypothesis, their aim was to examine the feasibility of SU-AVR in 13 consecutive high-risk patients with active infective aortic valve endocarditis ( 1 ).…”