Sutureless aortic valve replacement: a systematic review and meta-analysis

Abstract

Background: Sutureless aortic valve replacement (SU-AVR) has emerged as an innovative alternative for treatment of aortic stenosis. By avoiding the placement of sutures, this approach aims to reduce cross-clamp and cardiopulmonary bypass (CPB) duration and thereby improve surgical outcomes and facilitate a minimally invasive approach suitable for higher risk patients. The present systematic review and meta-analysis aims to assess the safety and efficacy of SU-AVR approach in the current literature.

Methods: Electronic searches were performed using six databases from their inception to January 2014. Relevant studies utilizing sutureless valves for aortic valve implantation were identified. Data were extracted and analyzed according to predefined clinical endpoints.

Results: Twelve studies were identified for inclusion of qualitative and quantitative analyses, all of which were observational reports. The minimally invasive approach was used in 40.4% of included patients, while 22.8% underwent concomitant coronary bypass surgery. Pooled cross-clamp and CPB duration for isolated AVR was 56.7 and 46.5 minutes, respectively. Pooled 30-day and 1-year mortality rates were 2.1% and 4.9%, respectively, while the incidences of strokes (1.5%), valve degenerations (0.4%) and paravalvular leaks (PVL) (3.0%) were acceptable.

Conclusions: The evaluation of current observational evidence suggests that sutureless aortic valve implantation is a safe procedure associated with shorter cross-clamp and CPB duration, and comparable complication rates to the conventional approach in the short-term.

Keywords: Sutureless; aortic valve replacement (AVR); meta-analysis; minimally invasive.

Figure 1

Summary of search strategy (PRISMA flow-chart) for relevant studies on sutureless aortic valve replacement (SU-AVR).

Figure 2

Operation characteristics for SU-AVR, including: (A) minimally invasive approach; (B) concomitant coronary artery bypass graft (CABG) performed. SU-AVR, sutureless AVR; WM, weighted mean; *, not reported.

Figure 3

Comparison of cardiopulmonary bypass (CBP) and cross-clamp durations for overall, isolated and minimally invasive approaches to sutureless AVR (MI SU-AVR). Recent Society of Thoracic Surgeons (STS) National Database values (25) for CBP and cross-clamp duration for isolated conventional AVR were included as a “benchmark” comparator for SU-AVR.

Figure 4

Forest plot of pooled estimates for (A) 1-year mortality; (B) stroke; (C) endocarditis, for patients undergoing SU-AVR; (D) paravalvular leakage. The estimate proportion of each trial corresponds to the middle of the squares, and the horizontal line shows the 95% confidence interval (CI). For each subgroup, the sum of the statistics, along with the summary proportion, is represented by the middle of the solid diamonds. A test of heterogeneity between the trials within a subgroup is also given adjacent to the summary statistics. SU-AVR, sutureless AVR.

Figure 5

Correlation between midpoint of study period and (A) % minimally invasive approach; and (B) % paravalvular leak (PVL) for Perceval S sutureless valves.

Figure 6

Hemodynamic outcomes of SU-AVR at up to 12-month follow-up. (A) Change in mean gradient and peak gradient after SU-AVR; (B) change in effective orifice area after SU-AVR. The solid line indicates the pooled results of the meta-analysis while the dashed lines represent 95% CI. Open circle, preoperative; closed triangle, discharge; closed diamond, 6-month follow-up; closed square, 12-month follow-up; closed circle, 2-year follow-up. SU-AVR, sutureless AVR; CI, confidence interval.

Figure S1

Funnel plot and trim-and-fill analysis of all-cause mortality for sutureless aortic valve replacement (SU-AVR). Open circles represents studies included in the current meta-analysis while black-filled circles represent potential missing studies in the current literature. Lower white diamond represents log odd ratios of included studies, while black diamond represents new log odds ratio after accounting for potential missing studies. This trim-and-fill analysis demonstrated that there were no missing studies that would have accounted for publication bias.