title: Treating the patients in the 'grey-zone' with aortic valve disease: a comparison among conventional surgery, sutureless valves and transcatheter aortic valve replacement.
abstract: OBJECTIVE
  Although the use of transcatheter aortic valve replacement (TAVR) has recently become an attractive strategy in extremely high-risk patients undergoing aortic valve replacement (AVR), the most appropriate treatment option in patients with an intermediate- to high-risk profile with conventional surgery (sAVR), TAVR or novel options, such as sutureless valves, has been widely debated.
  
  
  METHODS
  One hundred and sixty-three consecutive patients with intermediate to high risk were prospectively enrolled and selected to undergo sAVR (Group 1: G1, n = 55), sutureless valve implantation (Group 2: G2, n = 53) or TAVR (Group 3: G3, n = 55) following a multidisciplinary evaluation including frailty, anatomy and degree of atherosclerotic disease of the aorta/peripheral vessels. The mean logistic EuroSCORE (G1 = 21.3 ± 12.7 vs G2 = 16 ± 11.7 vs G3 = 20.4 ± 12.7, P = 0.06) and preoperative demographics, such as age, gender and left ventricular ejection fraction, were similar: of note, chronic obstructive pulmonary disease was more frequent in TAVI patients (G1 = 27.2% vs G2 = 15.1% vs G3 = 47%; P <0.01). The Perceval S sutureless valve was used in Group 2, whereas TAVR was performed with a Corevalve prosthesis.
  
  
  RESULTS
  Post-procedural pacemaker implantation (G1 = 1.8% vs G2 = 2% vs G3 = 25.5%, P <0.001) and peripheral vascular complications (G1 = 0% vs G2 = 0% vs G3 = 14.5%, P <0.001) occurred more frequently in patients undergoing TAVR. Hospital mortality was similar among the groups (G1 = 0% vs G2 = 0% vs G3 = 1.8%, P = NS). At the 24-month follow-up, overall survival free from major adverse cardiac and cerebrovascular events and prosthetic regurgitation was better in patients who had undergone sAVR and sutureless valves than those who had undergone TAVR (G1 = 95.2 ± 3.3% vs G2 = 91.6 ± 3.8% vs G3 = 70.5 ± 7.6%; P = 0.015).
  
  
  CONCLUSIONS
  This preliminary study suggests that the use of TAVR in patients with an intermediate- to high-risk profile is associated with a higher rate of perioperative complications and decreased survival at the 24-month follow-up compared with the use of conventional surgery or sutureless valves.
authors.affiliation: Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.
authors.forename: Claudio
authors.initials: C
authors.lastname: Muneretto
authors.affiliation: Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy gianluigi.bisleri@gmail.com.
authors.forename: Gianluigi
authors.initials: G
authors.lastname: Bisleri
authors.affiliation: Division of Cardiac Surgery, Ospedale Carlo Poma, Mantova, Italy.
authors.forename: Annalisa
authors.initials: A
authors.lastname: Moggi
authors.affiliation: Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.
authors.forename: Lorenzo
authors.initials: L
authors.lastname: Di Bacco
authors.affiliation: Division of Cardiology, Ospedale Bolognini, Seriate, Italy.
authors.forename: Maurizio
authors.initials: M
authors.lastname: Tespili
authors.affiliation: Division of Cardiac Surgery, University of Brescia Medical School, Brescia, Italy.
authors.forename: Alberto
authors.initials: A
authors.lastname: Repossini
authors.affiliation: Division of Cardiac Surgery, Ospedale Carlo Poma, Mantova, Italy.
authors.forename: Manfredo
authors.initials: M
authors.lastname: Rambaldini
mesh_terms: 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 / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D016009:Chi-Square Distribution; D015897:Comorbidity; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation / Q000379:methods* / Q000401:mortality; D017052:Hospital Mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D016015:Logistic Models; D008297:Male; D011183:Postoperative Complications / Q000401:mortality / Q000628:therapy; D011446:Prospective Studies; D011474:Prosthesis Design; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D016896:Treatment Outcome
keywords: Aortic valve replacement; Complications; Heart valve; Percutaneous; Surgery