SUTURELESS VALVE ASSOCIATED A MINIMALLY INVASIVE APPROACH COVERS THE GAP BETWEEN TRANSCATHETER AORTIC VALVE IMPLANTATION AND CONVENTIONAL AORTIC VALVE REPLACEMENT
Antonio Miceli, M.D., Ph.D,
Istituto Clinico Sant’Ambrogio, Gruppo Ospedaliero San Donato, Milano, Italy
Aortic valve replacement with sutured stented valve is the treatment of choice in patients with severe aortic valve stenosis. This surgical approach has shown excellent mortality, morbidities and long-term survival. Nevertheless, this procedure has been often denied to the high-risk patients with severe aortic stenosis due to the advanced age, numerous comorbidities and poor predicted outcomes. In this setting, transcatheter aortic valve implantation (TAVI) has been considered a valid option in the treatment of high-risk patients, as it has shown to be superior to medical therapy and not inferior to conventional surgery in terms of mortality and early survival. These enthusiastic results have brought the cardiac community to increase the number of TAVI procedures, with the aim of decreasing the invasiveness of surgical operations even in lower risk patients. However, it has been reported that TAVI was associated with higher incidence of neurological events, vascular complications and paravalvular leakages when compared with the conventional surgery.
From the dualism between the surgical and transcatheter approaches, a new valve technology has been developed as an additional treatment option to the high-risk patient undergoing aortic valve replacement to simplify and standardize the surgical procedure and facilitate the minimally invasive approach. The sutureless and rapid deployment aortic valves have been designed to avoid or minimize passing stiches through the annulus and suture knotting to decrease the surgical trauma to the aortic annulus and consequently reduce the operative times. Many studies have reported excellent clinical results in terms of postoperative outcomes, hemodynamic performances, structural valve deterioration and freedom from reoperation up to 5 years. These results have been confirmed even in the setting of minimally invasive surgery. As consequence, these valves have been recommended for those patients belonging to the “gray zone” between TAVI and conventional surgery.
The potential benefits of sutureless and rapid deployment valves when compared with TAVI are the decreased paravalvular leak rate and decreased need for postoperative pacemakers. Furthermore, the surgical approach has the advantage of removing the calcified stenotic valve, a possible cause of neurological events. A large European study reported excellent outcomes, hemodynamic results and 1 year survival with sutureless and minimally invasive aortic valve replacement with the sutureless valve through a right minithoracotomy approach or ministernotomy. These outstanding results have raised the hypothesis that the combination of minimally invasive surgery with the sutureless technology might be considered the “real alternative” to the TAVI technology in intermediate and high risk operable patients. In this setting, a recent meta-analysis has shown that sutureless valves are associated with a 70% reduction of early mortality and 90% reduction of postoperative paravalvular leakage. Paravalvular leakage is now considered a negative outcome, because it has been demonstrated that even mild regurgitation is associated with lower survival at 2 and 5 years. More studies and a proper randomized trial are required to confirm these data.
In conclusion, based on the current literature data, TAVI is recommended for inoperable and very high-risk patients whereas sutureless and rapid deployment valve in combination with any minimally invasive approach are advised for medium risk operable patients. The low risk patients may benefit of a minimally invasive approach but still with a conventional sutured valve. In this setting, the role of the “heart team” is essential for the correct indication, minimizing the potential risks. While we are waiting some robust data and recommendations from the American and European Societies, we will expect that the future be without suture!!!