title: Aortic valve replacement in geriatric patients with small aortic roots: are sutureless valves the future?
abstract: OBJECTIVE
  Aortic valve replacement (AVR) in geriatric patients (>75 years) with small aortic roots is a challenge. Patient-prosthesis mismatch and the long cross-clamp time necessary for stentless valves or root enlargement are matters of concern. We compared the results of AVR with sutureless valves (Sorin Perceval), against those with conventional biological valves.
  
  
  METHODS
  Between April 2007 and December 2012, 120 isolated AVRs were performed in patients with a small annulus (<22 mm) at our centre. In 70 patients (68 females, age 77.4 ± 5.5 years), conventional valves (C group) and in 50 patients (47 females, age 79.8 ± 4.5 years), sutureless valves (P group) were implanted. The Logistic EuroSCORE of the C group was 16.7 ± 10.4 and that of the P group 20.4 ± 10.7, (P = 0.054). Minimal-access surgery was performed in 4.3% (3/70) patients in the C group and 72% (36/50) patients in the P group.
  
  
  RESULTS
  The cardiopulmonary bypass (CPB) and cross-clamp times of the C group were 75.3 ± 23 and 50.3 ± 14.2 min vs 58.7 ± 20.9 and 30.1 ± 9 min in the P group, (P < 0.001). In the C group, two annulus enlargements were performed. Thirty-day mortality was 4.3% (n = 3) in the C group and 0 in the P group, (n.s.). At follow-up (up to 5 years), mortalities were 17.4% (n = 12) in the C group and 14% (n = 7) in the P group, (n.s.).
  
  
  CONCLUSIONS
  This study highlights the advantages of sutureless valves for geriatric patients with small aortic roots reflected by shorter cross-clamp and CPB times, even though most of these patients were operated on via a minimally invasive access. Moreover, due to the absence of a sewing ring, these valves are also almost stentless, with greater effective orifice area (EOA) for any given size. This may potentially result in better haemodynamics even without the root enlargement. This is of advantage, as several studies have shown that aortic root enlargement can significantly increase the risks of AVR. Moreover, as seen in this series, these valves may also enable a broader application of minimally invasive AVR.
authors.affiliation: Division of Cardiac-Thoracic, Transplantation and Vascular Surgery, Hannover Medical School, Hannover, Germany.
authors.forename: Malakh
authors.initials: M
authors.lastname: Shrestha
authors.forename: Ilona
authors.initials: I
authors.lastname: Maeding
authors.forename: Klaus
authors.initials: K
authors.lastname: Höffler
authors.forename: Nurbol
authors.initials: N
authors.lastname: Koigeldiyev
authors.forename: Georg
authors.initials: G
authors.lastname: Marsch
authors.forename: Thierry
authors.initials: T
authors.lastname: Siemeni
authors.forename: Felix
authors.initials: F
authors.lastname: Fleissner
authors.forename: Axel
authors.initials: A
authors.lastname: Haverich
mesh_terms: D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000503:physiopathology / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000175:diagnosis / Q000401:mortality / Q000503:physiopathology / Q000601:surgery*; D002315:Cardiopulmonary Bypass; D016009:Chi-Square Distribution; D003250:Constriction; D005060:Europe; D005240:Feasibility Studies; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000401:mortality; D006439:Hemodynamics; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D015999:Multivariate Analysis; D018579:Patient Selection; D010865:Pilot Projects; D016016:Proportional Hazards Models; D011446:Prospective Studies; D011474:Prosthesis Design; D012307:Risk Factors; D013536:Suture Techniques; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aortic valve stenosis; Elderly patients; Small aortic root; Sutureless aortic valve