Sutureless aortic valve replacement could be first-line therapy for grey-area patients

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A study in the Journal of Thoracic and Cardiovascular Surgery shows that minimally invasive surgical aortic valve replacement with a sutureless valve is associated with less paravalvular leak and reduced mortality compared with transcatheter aortic valve implantation (TAVI)—indicating that minimally invasive sutureless surgical aortic valve replacement could become the first-line therapy for patients in the grey area between TAVI and open surgical valve replacement.

The authors Giuseppe Santarpino (Klinik für Hezchirugie, Klinikum Nürnberg, Nürnberg, Germany) and others report that the use of a sutureless device in surgical aortic valve replacement have enabled shorter procedural times, adding that it also allows “easy implantation of the aortic valve prosthesis when using a minimally invasive surgical approach”. They explain with the Perceval S sutureless valve (Sorin), the native diseased valve is removed and the bioprosthetic valve is mounted on expandable stent fixed to the aortic valve annulus without sutures; therefore, it allows for a hybrid solution that is “somewhere between conventional aortic valve replacement and the transcatheter approach”. The aim of the study was to compare outcomes of patients who had undergone TAVI with the Sapien or Sapien XT (Edwards Lifesciences) with those who had undergone minimally invasive surgery with the Perceval S valve.


Santarpino et al reviewed data from all patients with diagnosed with severe aortic valve stenosis with an indication of surgery at their centre from 2010. Of 244 patients, 122 underwent TAVI (all aged ≥65 years and at high risk for surgery) and 122 underwent the minimally invasive approach (all aged ≥65 years and at low risk for surgery). From this group of patients, the authors identified 37 matching pairs. They noted: “At discharge, the incidence of aortic regurgitation caused by postprocedural paravalvular leakage was higher in the TAVI group than in the sutureless group (13.5% vs. 0%; p=0.027).”


The TAVI group also had a significantly lower rate of survival at the median follow-up point of 18.9±10.1 months—86.5% vs. 97.3% for the sutureless group (p=0.015). However when the authors looked the survival rate of TAVI patients who did not have paravalvular leak (17) vs. that of patients in the sutureless group, they did not find a significant difference between groups (100% vs. 97.3%, respectively). Additionally, minimally invasive sutureless aortic valve replacement was associated with a higher rate of freedom from rehospitalisation (86.5% vs. 54.1% for the TAVI group; p=0.054) and TAVI was associated with a non-significant trend towards a higher rate of neurologic events.


The authors concluded: “Removal of the diseased native valve may enhance procedural quality by avoiding paravalvular leak. In combination with minimally invasive sutureless aortic valve replacement, this may become first-line treatment for high-risk patients considered in the grey zone between TAVI and conventional surgery. Further, larger, prospective, randomised studies are warranted to confirm our results.”

 

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