Aortic valve replacement (AVR) is a cornerstone treatment for severe aortic valve diseases, particularly aortic stenosis, which has a growing prevalence in aging populations. The emergence of less invasive surgical approaches and advanced valve technologies, such as sutureless prostheses, has transformed the surgical landscape, aiming to reduce surgical time, improve outcomes, and promote faster recovery. This cross-sectional study, published in the Brazilian Journal of Cardiovascular Surgery, investigates whether the use of a sutureless prosthesis (PERCEVAL®) in AVR via ministernotomy offers a clinical advantage over conventional stented bioprostheses, particularly focusing on CPB and cross-clamping times.
The study analyzed 93 patients who underwent AVR through a ministernotomy approach between February 2015 and February 2021 at a single center in Brazil. Of these, 12 patients received the sutureless PERCEVAL® valve, while 81 received conventional biological valves. The median age of the entire cohort was 61 years, but those receiving PERCEVAL® were significantly older (76.5 years) than the conventional group (60 years), which aligns with typical sutureless valve indications due to their suitability in elderly patients.
Surgical outcomes were evaluated based on intraoperative parameters, hospital course, and echocardiographic findings. CPB times were 61 minutes for the conventional group and 59.5 minutes for the sutureless group (P=0.143), while cross-clamping times were 41 minutes versus 39.5 minutes, respectively (P=0.058). These results indicate no statistically significant differences, suggesting that the use of a sutureless valve in this setting does not drastically shorten operative times when compared to experienced conventional implantation.
Postoperative hospital and ICU stays also showed comparable results, with a median ICU stay of 2 days and overall hospital stay of 8 days in both groups. Importantly, there were no deaths, myocardial infarctions, or tamponade events within 30 days post-surgery in either group, highlighting the safety of both techniques.
Echocardiographically, patients from both groups demonstrated significant postoperative improvements, including reduced left ventricular mass and systolic gradients. The sutureless group exhibited a notable reduction in both maximum and mean systolic gradients, which may reflect improved hemodynamic performance of the PERCEVAL® valve. However, between-group differences in echocardiographic parameters were not statistically significant.
From an epidemiological perspective, the majority of the study population had hypertension (80.2%), dyslipidemia (34.1%), and diabetes (25.3%), reflecting a typical cardiovascular risk profile. There were no significant differences in comorbidities between groups, except for age. Interestingly, patients in the sutureless group also had a higher prevalence of coronary artery disease, which could have influenced the surgical decision-making process.
A strength of this study lies in its standardized surgical technique, as all procedures were conducted by the same experienced team. This reduces variability and allows for more reliable comparisons. However, the limited sample size, particularly for the sutureless group, and the retrospective design present limitations in terms of generalizability and causality.
The findings align with other international studies suggesting that while sutureless valves may simplify implantation and potentially reduce operative times, the actual clinical differences may be minimal in experienced hands. Additionally, the economic implications of sutureless valve use remain a key consideration. While these valves are more expensive upfront, they may offer cost savings by reducing complications, reoperations, and hospitalization duration in certain patient populations.
Notably, the PERCEVAL® valve is not yet widely available in Brazil’s public healthcare system, which limits its broader applicability. However, given its comparable outcomes and possible advantages in elderly or high-risk patients, integrating such technology into public systems could offer long-term benefits if supported by future large-scale, randomized controlled trials.
The study concludes that sutureless AVR via ministernotomy is a feasible and safe alternative to conventional techniques, with no significant differences in short-term outcomes, hospital stays, or cardiac function. Future research should focus on randomized studies to validate these findings and support their inclusion in national and international surgical guidelines.
Study ranking = 3 (moderate quality). This is a single-center, retrospective cross-sectional study with a small sample size for the sutureless group. While informative, it lacks the rigor of a randomized controlled trial.
