title: Sutureless, rapid deployment valves and stented bioprosthesis in aortic valve replacement: recommendations of an International Expert Consensus Panel.
abstract: OBJECTIVE
  After a panel process, recommendations on the use of sutureless and rapid deployment valves in aortic valve replacement were given with special respect as an alternative to stented valves.
  
  
  METHODS
  Thirty-one international experts in both sutureless, rapid deployment valves and stented bioprostheses constituted the panel. After a thorough literature review, evidence-based recommendations were rated in a three-step modified Delphi approach by the experts.
  
  
  RESULTS
  Literature research could identify 67 clinical trials, 4 guidelines and 10 systematic reviews for detailed text analysis to obtain a total of 28 recommendations. After rating by the experts, 12 recommendations were identified and degree of consensus for each was determined. Proctoring and education are necessary for the introduction of sutureless valves on an institutional basis as well as for the individual training of surgeons. Sutureless and rapid deployment should be considered as the valve prosthesis of first choice for isolated procedures in patients with comorbidities, old age, delicate aortic wall conditions such as calcified root, porcelain aorta or prior implantation of aortic homograft and stentless valves as well as for concomitant procedures and small aortic roots to reduce cross-clamp time. Intraoperative transoesophageal echocardiography is highly recommended, and in case of right anterior thoracotomy, preoperative computer tomography is strongly recommended. Suitable annular sizes are 19-27 mm. There is a contraindication for bicuspid valves only for Type 0 and for annular abscess or destruction due to infective endocarditis. Careful but complete decalcification of the aortic root is recommended to avoid paravalvular leakage; extensive decalcification should be avoided not to create annular defects. Proximal anastomoses of concomitant coronary artery bypass grafting should be placed during a single aortic cross-clamp period or alternatively with careful side clamping. Available evidence suggests that the use of sutureless and rapid deployment valve is associated with (can translate into) reduced early complications such as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions and renal replacement therapy, respectively, and may result in reduced intensive care unit and hospital stay in comparison with traditional valves.
  
  
  CONCLUSIONS
  The international experts recommend various benefits of sutureless and rapid deployment technology, which may represent a helpful tool in aortic valve replacement for patients requiring a biological valve. However, further evidence will be needed to reaffirm the benefit of sutureless and rapid deployment valves.
authors.affiliation: University of Ljubljana School of Medicine and University Medical Center Ljubljana, Ljubljana, Slovenia bgersak@maat.si.
authors.forename: Borut
authors.initials: B
authors.lastname: Gersak
authors.affiliation: Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany.
authors.forename: Theodor
authors.initials: T
authors.lastname: Fischlein
authors.affiliation: Centre Hospitalo-Universitaire Brabois, Université de Lorraine, Vandoeuvre les Nancy, France.
authors.forename: Thierry A
authors.initials: TA
authors.lastname: Folliguet
authors.affiliation: U.Z. Gasthuisberg, Leuven, Belgium.
authors.forename: Bart
authors.initials: B
authors.lastname: Meuris
authors.affiliation: McMaster University, Hamilton, ON, Canada.
authors.forename: Kevin H T
authors.initials: KH
authors.lastname: Teoh
authors.affiliation: Austin Health and Royal Melbourne Hospital, Melbourne, Australia.
authors.forename: Simon C
authors.initials: SC
authors.lastname: Moten
authors.affiliation: Ospedale del Cuore G. Pasquinucci, Fondazione Toscana G. Monasterio, Massa, Italy.
authors.forename: Marco
authors.initials: M
authors.lastname: Solinas
authors.affiliation: Istituto Clinico Humanitas, Milan, Italy.
authors.forename: Antonio
authors.initials: A
authors.lastname: Miceli
authors.affiliation: Medical School Graz, Graz, Austria.
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Oberwalder
authors.affiliation: Ospedale di Mantova, Mantua, Italy.
authors.forename: Manfredo
authors.initials: M
authors.lastname: Rambaldini
authors.affiliation: Trillium Cardiovascular Associates, Mississauga, ON, Canada.
authors.forename: Gopal
authors.initials: G
authors.lastname: Bhatnagar
authors.affiliation: Columbia University Medical Center, New York, NY, USA.
authors.forename: Michael A
authors.initials: MA
authors.lastname: Borger
authors.affiliation: University of Montreal, Montreal, QC, Canada.
authors.forename: Denis
authors.initials: D
authors.lastname: Bouchard
authors.affiliation: CHU le Bocage, Dijon, France.
authors.forename: Olivier
authors.initials: O
authors.lastname: Bouchot
authors.affiliation: Freeman Hospital, Newcastle, UK.
authors.forename: Stephen C
authors.initials: SC
authors.lastname: Clark
authors.affiliation: Medical School Graz, Graz, Austria.
authors.forename: Otto E
authors.initials: OE
authors.lastname: Dapunt
authors.affiliation: Istituto Clinico Sant' Ambrogio, Milan, Italy.
authors.forename: Matteo
authors.initials: M
authors.lastname: Ferrarini
authors.affiliation: Medizinische Universitaet Wien, Vienna, Austria.
authors.forename: Guenther
authors.initials: G
authors.lastname: Laufer
authors.affiliation: Ospedale Ferrarotto, Catania, Italy.
authors.forename: Carmelo
authors.initials: C
authors.lastname: Mignosa
authors.affiliation: Blackpool Victoria Hospital, Blackpool, UK.
authors.forename: Russell
authors.initials: R
authors.lastname: Millner
authors.affiliation: Cliniques Universitaires St-Luc, Brussels, Belgium.
authors.forename: Philippe
authors.initials: P
authors.lastname: Noirhomme
authors.affiliation: Klinikum Nuernberg, Paracelsus Medical University, Nuremberg, Germany.
authors.forename: Steffen
authors.initials: S
authors.lastname: Pfeiffer
authors.affiliation: Hospital University Germans Trias I Pujol, Barcelona, Spain.
authors.forename: Xavier
authors.initials: X
authors.lastname: Ruyra-Baliarda
authors.affiliation: Medizinischen Hochschule Hannover, Hannover, Germany.
authors.forename: Malakh
authors.initials: M
authors.lastname: Shrestha
authors.affiliation: Mayo Clinic, Rochester, MN, USA.
authors.forename: Rakesh M
authors.initials: RM
authors.lastname: Suri
authors.affiliation: Fondazione Poliambulanza, Brescia, Italy.
authors.forename: Giovanni
authors.initials: G
authors.lastname: Troise
authors.affiliation: Herz- und Gefäß-Klinik Bad Neustadt, Bad Neustadt an der Saale, Germany.
authors.forename: Anno
authors.initials: A
authors.lastname: Diegeler
authors.affiliation: Institut Mutualiste Montsouris, Paris, France.
authors.forename: Francois
authors.initials: F
authors.lastname: Laborde
authors.affiliation: University Hospital Dupuytren, Limoges, France.
authors.forename: Marc
authors.initials: M
authors.lastname: Laskar
authors.affiliation: King Fahad National Guard Hospital, Riyadh, Saudi Arabia.
authors.forename: Hani K
authors.initials: HK
authors.lastname: Najm
authors.affiliation: Istituto Clinico Sant' Ambrogio, Milan, Italy.
authors.forename: Mattia
authors.initials: M
authors.lastname: Glauber
mesh_terms: D001021:Aortic Valve / Q000601:surgery*; D001705:Bioprosthesis; D032921:Consensus; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000295:instrumentation* / Q000379:methods*; D006801:Humans; D015607:Stents
keywords: Aortic valve replacement; Rapid deployment valve; Recommendations; Stented aortic valve prosthesis; Sutureless valve