Aims Sutureless valves became an alternative to standard bioprostheses, allowing surgeons to significantly reduce cross-clamping and extracorporeal circulation times, with a potential positive impact on major postoperative complications. The aim of this European multicentre study was to evaluate the safety and efficacy of sutureless valves in patients with an intermediate-risk profile undergoing aortic valve replacement (AVR). Methods We investigated early and mid-term outcomes of 518 elderly patients with aortic stenosis at intermediate-risk profile (mean STS Score 6.1 ± 2%) undergoing AVR with sutureless aortic valve. Primary endpoints were 30-day mortality and freedom from all-cause death at follow-up. The secondary endpoint was survival freedom from MACCEs [all-cause death, stroke/transitory ischemic attack (TIA), bleeding, myocardial infarction, aortic regurgitation Grade II, endocarditis, reintervention and pacemaker implant; VARC 1--2 criteria]. Results Sutureless valve implantation was successfully performed in 508 patients, with a procedural success rate of 98.1% (508/518) as per VARC criteria. Concomitant myocardial revascularization [coronary artery bypass grafting (CABG)] was performed in 74 out of 518 patients (14.3%). In-hospital mortality was 1.9% (10/518). Postoperative complications included revision for bleeding (23/518; 4.4%), prolonged intubation more than 48h (4/518; 0.7%), acute renal failure (14/518; 2.7%), stroke/TIA (11/518; 2.1%), pacemaker implantation (26/518; 5.1%) and aortic regurgitation more than Grade II (7/518; 1.4%). At 48-month follow-up, Kaplan–Meier overall survival and freedom from MACCEs in patients receiving isolated AVR were 83.7% [95% confidence interval (95% CI): 81.1–86.3] and 78.4% (95% CI: 75.5–81.4), respectively, while in patients with concomitant CABG, Kaplan–Meier overall survival and freedom from MACCEs were 82.3% (95% CI: 73.3–91.3) and 79.1% (95% CI: 69.9–88.3), respectively. Conclusion The use of sutureless aortic valves in elderly patients with an intermediate-risk profile provided excellent early and mid-term outcomes, providing a reliable tool in patients undergoing surgical AVR in this specific subset of population. These preliminary data need to be investigated with a TAVI control-group in further studies.

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Mitral annular calcification (MAC) represents an important risk factor in mitral valve (MV) surgery. Despite several procedures having been described, no surgical treatment of choice has been established so far: whether a decalcification should be systematically carried out, or if the MV should be preferentially repaired rather than replaced. A review of the literature on patients undergoing MV surgery associated with MAC was performed. Studies were excluded if dealing with endovascular procedures or emergency surgery for associated endocarditis. Case reports were also not considered in the final analysis. The literature search identified 1429 potentially eligible studies, and 25 papers were eventually included. Several surgical techniques were described to approach this challenging condition. During MV surgery, the presence of MAC favors the occurrence of suboptimal intraoperative outcomes. MAC-related complications such as atrioventricular groove rupture, cerebrovascular accident, new permanent pacemaker implantation, intraoperative conversion from valve repair to replacement and mortality were analyzed.MV surgery in the presence of MAC considerably impacts the postoperative outcomes in terms of morbidity and mortality. A great variability of surgical techniques is reported, suggesting the need for standardization of the approach.