Sutureless valve surgery is a recent medical advancement in the field of minimally-invasive valve surgeries. Up till now minimally invasive aortic valve replacement and the transcatheter aortic valve replacement (TAVR/TAVI) were considered the safest options in comparison to general invasive valve replacement surgeries, which caused a lot of surgical stress and trauma for the patient.
The new advanced method of valve replacement avoids the placement and tying of sutures and hence, is referred to as the sutureless valve surgery and even rapid deployment of aortic valves. The new method is advantageous over others because it reduces cross-clamp and cardiopulmonary bypass duration. This helps to carry out complex cardiac interventions with much more ease and while maintaining hemodynamic outcomes and low paravalvular leak rates. However, since the method is fairly new, the applicability of the procedure is limited to certain specific patient cases, as deemed fit by the surgeon.
The concept of sutureless valve surgery was introduced more than 50 years ago; however, they have been just recently redeveloped based on the learnings and experiences from TAVI. However, even until now, a majority of valve replacement procedures are conducted using the sutured biological valves.
Advantages of Sutureless Valve Surgery
Some of the common advantages of sutureless valve surgery over other invasive, as well as minimally-invasive methods, include:
- Excellent hemodynamic performance
- The high rate of freedom from structural valve degeneration (up to 15 years)
- Low paravalvular leak rates
- Less surgical stress and trauma
- High recovery rate
- Shorter hospital stay
- Reduced cross-clamp and cardiopulmonary bypass duration
- Perceval prosthetic valve is easy to implant and safe
- Reduced operative time
- Simplified surgical implantation
- Fewer post-operative complications
- Comparatively reasonable
- Rapid deployment
Challenges of Sutureless Valve Surgery
Since the method is fairly new, there are a couple of unexplored dimensions and challenges. Some of the common challenges in sutureless valves surgeries include:
- Lack of enough information on the new generation of prostheses
- Rare chances of dislodgement, malposition, leakage, aortic tear
- Could require multiple attempts
But given the advantages of the sutureless valve surgeries over other methods, surgeons increasingly prefer the former since it represents a natural evolution. Also, when patients suffer from multiple comorbidities or poor ventricular function, a sutureless valve surgery may be the ideal choice of treatment. Additionally, sutureless valve surgery is an optimal choice for multiple valve or concomitant procedures. Since sutureless valves produce lower gradients as compared to the sutured alternatives, this method works well in patients that have small aortic root.
Types of Sutureless Valves
Currently, there are two types of sutureless valves available for treatment, namely Sorin’s Perceval and Edwards’ Intuity. Both use bovine tissue but the former uses a nitinol stent, whereas the latter uses a stainless steel one. The Perceval stent requires no suture at all, while the Intuity one requires three basic sutures. Also, Perceval is a collapsible valve but Intuity is not.
The Intuity stent is based on expandable stainless steel and cloth-covered frame, which is placed with the help of a balloon catheter and expands the frame within the right annular position. This requires three sutures.
On the other hand, the Perceval sutureless prosthesis uses the ‘memory’ of the nitinol metal frame, helping it to deploy and position the valve without any sutures.
Similarities between Sutureless Valve Surgery and Traditional Methods
Sutureless valve surgery has several similarities with traditional valve surgeries such as conventional prostheses. These include:
- Both procedures need surgical incisions, either full median sternotomy incision or minimally invasive incisions such as mini-sternotomy and mini-thoracotomy
- Sutureless valve surgery does not preclude the need for CPB and aortic cross-clamping completely.
- Both approaches excise the diseased valve
Difference between Sutureless Valve Surgery and Traditional Methods
There are critical differences between sutureless valve surgery and other traditional methods, such as:
- Sutureless valves do not require extensive placement and tying of sutures
- Unlike the traditional methods, the sutureless valves are sized and deployed with a maximum of three sutures to perfectly attach to the aortic root orifice
- Sutureless valve surgery is a shorter duration operation unlike the traditional long procedures
- Even though both sutureless valve surgery and the TAVI prosthesis follow the same principle, yet the former does not need crimping of the pericardium like the TAVI process
- A TAVI procedure gains indirect visualization of the implantation and target location through fluoroscopy; whereas the sutureless valve surgery has direct visualization of the implantation and target office location
- The current TAVI protocols exclude excision of the diseased calcified aortic valve, in contrast to that of the sutureless valve surgery
Overall, even though there is a high demand for minimally-invasive procedures and sutureless valve surgery is a great choice, yet there is low patient adoption of the novel technique of valve repair or replacement.