Avoiding oversizing in sutureless valves leads to lower transvalvular gradients and less permanent pacemaker implants postoperatively

Abstract

OBJECTIVES The aim of this study was to evaluate the impact of changing the sizing strategy in aortic valve replacement using the Perceval sutureless prosthesis on haemodynamic outcomes and postoperative pacemaker implantation. METHODS Retrospective analysis of patients implanted with the Perceval valve between 2007 and 2019 was performed by comparing patients implanted before the modification of sizing strategy (OLD group) and after (NEW group). The outcome parameters evaluated were the implanted prosthesis size, haemodynamical profile and postoperative pacemaker implantation. RESULTS The entire patient cohort (784 patients) consisted of 52% female patients, with a mean age of 78.53 [standard deviation (SD): 5.8] years and a mean EuroSCORE II of 6.3 (range 0.7–76). In 55.5% of cases, surgery was combined. The NEW cohort had more male patients (54.6% vs 43.4%) (P = 0.002). Mean implanted valve size, corrected for body surface area, was significantly lower in the NEW cohort (13.1, SD: 1.4 vs 13.5, SD: 1.4 mm/m2, P < 0.001). The 30-day mortality was 3.4%. Peak and mean transvalvular gradients at discharge were significantly lower in the NEW versus OLD groups: 24.4 mmHg (SD: 9.2) versus 28.4 mmHg (SD: 10.3) (P < 0.001) and 13.6 mmHg (SD: 5.3) versus 15.5 mmHg (SD: 6.0) (P < 0.001). The mean effective opening area and the indexed effective opening area, respectively, increased from 1.5 cm2 (SD: 0.5) and 0.85 cm2/m2 (SD: 0.27) in the OLD group to 1.7 cm2 (SD: 0.5) and 0.93 cm2/m2 (SD: 0.30) in the NEW group (P < 0.001). No difference was found in paravalvular leakage ≥1/4. Centrovalvular leakage ≥1/4 significantly decreased from 18% to 7.9% (P < 0.001). With the new sizing, the new postoperative pacemaker implantation rate decreased significantly from 11% to 6.1% (P = 0.016). CONCLUSIONS Correct sizing of sutureless aortic valves is crucial to obtain the best possible haemodynamics and avoid complications.

Sutureless Perceval Valve: Size Matters

“…Although these data are yet to be published, what we have found corroborates recent European reports that intraoperative obturator sizing alone tends to both oversize and undersize when compared with CT-based annular measurements. 13,17 In our experience, 36% of patients received an oversized Perceval valve based on intraoperative sizing, and oversizing was more common earlier on in our experience. As we have gained experience with sizing, we find that the preoperative CT and the intraoperative sizing are more in line with each other.…”

“…Because some data have shown a direct association between significant stent overexpansion and increased transvalvular gradients as well as increased rates of PPM, the sizing algorithm for the valve has been slightly altered. 13,17 It is currently recommended that the clear (smaller) side of the valve sizer must fit through the annulus and the white (larger) side should pass through the annulus, but with “light friction.” 17 If those factors are met, then the corresponding size valve should be chosen. So, how do you quantify light friction?…”

“…13,17 It is currently recommended that the clear (smaller) side of the valve sizer must fit through the annulus and the white (larger) side should pass through the annulus, but with "light friction." 17 If those factors are met, then the corresponding size valve should be chosen. So, how do you quantify light friction?…”

The importance of sizing in sutureless valves

“…We recently published our experience with Perceval, also looking at 2 cohorts in time, namely before and after 2017 [5]. A similar observation of a significantly decreased need for postoperative pacemakers from 11% to 6% was made, strengthening the observation made by Fabre.…”

Rapid-Deployment Aortic Valve Replacement: Patient Selection and Special Considerations

“…Szecel et al exhibited that the updated sizing strategy led to better prosthetic size, hemodynamics and PPI rate without increasing the incidence of PVL. 84 When the annular diameter is 27 mm or greater, SRDV should be avoided given the risk of PVL and device migration. Similarly, use of SRDV should be avoided when annular or aortic root enlargement may be required in patients with annular diameter smaller than 19 mm, because the deployed prosthetic valve would not be stabilized with significant risk of aortic root rupture.…”