Surgical Aortic Valve Replacement in Small Annuli: A Comparison between Sutureless Valve and Aortic Root Enlargement

Background: Surgical aortic valve replacement in small aortic annuli (SAA) ≤21 mm represent a technical challenge. Especially in stented valves, due to the struts and sewing rings, the inner diameter of a prosthetic valve is 5–7 mm smaller than expected resulting in a high risk of patient-prosthesis mismatch (PPM). The aim of this study was to analyze hemodynamics and perioperative outcomes of patients with SAA undergoing SAVR using sutureless Perceval (Corcym, Saluggia, Italy) size S and M (PER) versus aortic root enlargement (ARE).

Methods: Between 01/2012 and 05/2023, a total of 114 patients with SAA ≤21 mm undergoing SAVR were retrospectively included corresponding to 71 ARE and 43 PER. Hemodynamic, acute procedural, early clinical outcomes and 30-day mortality were analyzed.

Results: Out of 114 patients, 82 (72%) were female. Mean age was significantly higher for PER with 70.6 ± 7.3 years and 60.9 ± 12.5 years for ARE (p ≤ 0.001). STS-score and EuroSCORE II did not differ significantly between both groups (e.g., STS-score: 2.1 ± 1.0% for PER and 1.8 ± 1.7% for ARE; p = 0.366). Previous cardiac surgery was performed in 25.3% (18/71) before ARE and in 11.6% (5/43) before PER (p = 0.113). Mean aortic cross clamp (49.5 ± 11.7 min vs. 109.3 ± 35.6 min; p ≤ 0.001) and cardiopulmonary bypass (CPB; 86.2 ± 26.2 min vs. 162.9 ± 54.4 min, p ≤ 0.001) times were significantly lower after PER versus ARE. Rethoracotomy due to postoperative bleeding was necessary in 7.8% (9/114) with similarly rates in both cohorts (PER 9.3% (4/43) vs. ARE 9.8% (7/71); p = 0.922). Stroke appeared in 2.3% (1/43) after PER vs. 11.2% (8/71) after ARE (p = 0.091). Permanent pacemaker implantation was similar after PER 4.6% (2/43) and ARE 1.4% (1/71), (p = 0.277). Thirty-day mortality was low in both groups, with 4.2% (3/71) after ARE and even 0% after PER (p = 0,176). Cause of death after ARE was in one patient multiorgan failure and in two other patients respiratory failure. Postprocedure echocardiography demonstrated absence of any paravalvular leakage (PVL) in all but one patient with ≥ moderate PVL after ARE. Mean transvalvular pressure gradient was significantly lower after ARE (10.9 ± 4.9 mmHg) in comparison to PER (14.2 ± 5.9 mmHg; p = 0.003).

Conclusion: Our findings indicate that employing the PER and ARE treatment strategy for aortic annuli measuring ≤21 mm are technically feasible and clinically safe. ARE was associated with increased mean aortic cross-clamp and cardiopulmonary bypass times, yet resulting in improved hemodynamic outcomes in terms of mean transvalvular pressure gradient.

Publikationsverlauf

Artikel online veröffentlicht:
13. Februar 2024