Stentless sutureless and transcatheter valves: a comparison of the hemodynamic performance of different prostheses concept.

BACKGROUND: Stentless aortic valves have been developed to overcome obstructive limitations associated with stented bioprostheses. A new concept of surgical sutureless (SU) bioprosthesis has been developed in the last decade. In this multi-institutional study we sought to compare hemodynamics of different bioprosthesis concept as transcatheter (TAVR), Livanova Perceval S sutureless valve and Freedom Solo Stentless (FS) valve in patients undergoing aortic valve replacement (sAVR).

METHODS: From 2010 to 2016, 478 patients underwent sAVR with FS, 518 Perceval S and 367 patients underwent TAVR. After a propensity matched analysis 185 patients in each group were selected. Thirty-day postoperative clinical and echocardiographic parameters were evaluated. Echocardiographic hemodynamic data were also collected at 12 and 24 months.

RESULTS: Mean prosthesis diameter was 23.8±1.3 mm for FS, 23.2±2.1 mm for Perceval S and 25.1±2.6 mm for TAVR. In-hospital mortality was 2.0% for FS, 1.9% for Perceval, 5.8% for TAVR (P=0.02). Postoperative FS peak gradients were 15.6±9.1 mmHg (mean 7.6±5.4 mmHg); SU gradients were 18.7±9.1 mmHg (mean 10.9±5.4 mmHg), TAVR peak gradients were 14.7±9.1 mmHg (mean 6.1±5.4 mmHg) P=0.018 (P<0.001). Postoperative effective orifice area (EOA) was 1.94±0.7 cm² for FS, 1.6±0.7 cm² for SU and 1.97±0.7cm² for TAVR (P<0.001). There was no prostheses-patient-mismatch (PPM) in FS group, while 4 cases and 2 cases are reported in SU and TAVR respectively. Postoperative grade 2-3 paravalvular leak (PVL) was present in 4.3% for TAVR and 0.5% in SU valves and no cases in FS. Postoperative permanent pacemaker implant rate was 11.9% for TAVR (1.0%) in FS group and 5.4% in SU valves (P<0.001).

CONCLUSIONS: SU patients demonstrated post-operative excellent hemodynamic performance with smaller EROA and higher gradients compared to FS and TAVR. TAVR demonstrated higher mortality and pacemaker rates. Further studies are warrented to validate TAVR indications in this subset of patients.