Stenosis of the aortic valve is the most common
cardiac valve disease in developed countries affecting
approximately 3% of elderly patients. In parallel
with the growth of the aging population, aortic
stenosis becomes a more remarkable morbidity. Since
more elderly patients are recruited as candidates for
AVR, morbidities and concomitant risk factors should
be considered before the choice of the operative
technique.[
9-
14]
Muneretto et al.[15] suggested that the use of
transcatheter AVR in patients with an intermediateto-
high-risk profile was linked with a significantly
higher incidence of perioperative complications and
decreased survival at short and mid-term compared to
conventional surgery and sutureless valve implantation.
In this perspective, the choice of the appropriate valve
for every patient is a key point in planning the surgical
management of symptomatic aortic stenosis.
The primary aim of the present study was to
determine and compare early therapeutic outcomes
after AVR with sutureless, bioprosthetic, and
mechanical valves. Our study results demonstrated
that AVR maintained its position as the mainstay of
treatment in patients with severe and symptomatic
aortic stenosis. Improvement in cardiac functions is
reflected in echocardiographic findings such as mean
and maximum aortic gradient, as well as the thickness
of the posterior wall and interventricular septum.
However, early postoperative data did not yield any
noteworthy alterations regarding ejection fraction and
pulmonary arterial pressure. Hence, more accurate conclusions require further analyses of long-term
therapeutic results.
Perioperative data in our series showed that
durations of operation and cross-clamp and the
length of hospitalization and intensive care unit stay
were shorter in Group 1. However, these favorable
results for sutureless valves may be associated with
the characteristics of patients and comorbidities.
Cost-efficacy and the establishment of treatment
strategy on an individualized basis for every patient
are other key points to be considered. Although the
initial ejection fractions of patients in the sutureless
valve group were lower than the other groups, this
difference disappeared after AVR procedure. Based
on these findings, it can be speculated that sutureless
valves may result in more obvious beneficial effects in
the short-term.
Good clinical and hemodynamic outcomes have
been accomplished with AVR procedures with
sutureless, bioprosthetic, and mechanical valves. On
the other hand, determination of specific patient
selection criteria and the establishment of guidelines
is mandatory for optimizing treatment outcomes.
Aortic valve replacement using bioprostheses is more
preferential in elderly, whereas conventional AVR in
this population has an operative mortality ranging
between 4 to 10%.[16] Mataraci et al.[4] reported that
there was no mortality during hospital stay in the
sutureless valve group. Whether root enlargement
procedure increases mortality is still under debate.[17,18]
In our study, we observed that additional procedures
were accompanied with substantial morbidity compared
to AVR procedures alone.
In the current study, we presented our short-term
experience with three different valve types. Although
our data were insufficient for statistical analysis,
complications including mortality, neurological
hazards, central and paravalvular leak, and valve
dehiscence and migration were evaluated. Interestingly,
mortality and need for reoperation after AVR
were more frequent in the patients who underwent
additional surgical procedures such as CABG and root
enlargement procedure (Table 8). Dhareshwar et al.[18] also proposed that root enlargement procedure was
a contributor to mortality in the univariate analysis;
however, multivariate analysis results did not support
this hypothesis.
Table 8: Comorbidities and postoperative complications in three valve groups
The improvement in the mean and maximum
aortic gradients after surgery was consistent with the
report by Borger et al.[19] In parallel with the report
of Pollari et al.,[20] we also observed that sutureless
valve interventions were associated with decreased
operative and cross-clamp time and shorter duration of hospitalization and intensive care unit stay. Therefore,
this option can be of choice in elderly patients
who require additional procedures.[3-5] Furthermore,
reduction of operative time and cross-clamp time
may avoid side effects such as hemolysis, oxidative
stress, and hemolysis, thereby, improving the rates of
morbidity and mortality.[21]
Among complications encountered after AVR,
paravalvular leakage deserves a particular attention.
It has been suggested that insufficient sizing or
inappropriate decalcification of the annulus may be
responsible for this problem. Even if it may be timeconsuming,
the prosthesis must be positioned properly
and accurately.[22] Root enlargement procedures are
supposed not to amplify the surgical risk; however,
they should be omitted in elderly patients with severely
calcified aortic walls.[23]
Sutureless valves have been manufactured to
facilitate valve procedures, although they constitute a
technical challenge, and a learning curve is required.
Considering that sutureless procedures are not
completely devoid of risks, treatment strategy must be
tailored on an individualized basis for every candidate
of AVR. Increased awareness on complications and
close follow-up after surgery are crucial to achieve
reduced rates of morbidity and mortality.
Nonetheless, this study has some limitations
including the lack of long-term results and data
restricted to the experience of a single institution.
Many unidentified risk factors may have been
considered during decision-making process of
clinicians. Procedure-related costs constitute another
important aspect of AVR interventions. Moreover, we
were unable to perform a cost-efficacy analysis among
the treatment methods. Differences among the groups
regarding baseline characteristics such as age, ejection
fraction, NYHA class, and EuroSCORE mandate a
more cautious interpretation of our data. The effects
of social, environmental, and genetic factors can be
deemed other limitations before extrapolation of our
results to larger populations.
In conclusion, AVR procedures are the mainstay of
treatment for severe and symptomatic aortic stenosis.
Selection of sutureless, bioprosthetic, and mechanical
valves must be made according to the characteristics of
the patient including comorbidities and hemodynamic
profile. Further prospective, multi-center trials on
larger series are warranted to determine the safety,
efficacy, durability, advantages and disadvantages of
each valve type.
Declaration of conflicting interests
The authors declared no conflicts of interest with respect
to the authorship and/or publication of this article.
Funding
The authors received no financial support for the research
and/or authorship of this article.