Page 87 - Read Online

D’Abramo et al. Vessel Plus 2019;3:4 I http://dx.doi.org/10.20517/2574-1209.2018.41 Page 3 of 7

at higher risk can easily experience the so-called CPB side effects embracing a sequelae of side effects
[10]
involving several organs and apparatus . Alternative minimally invasive options has led to “sutureless”
or rapid deployment aortic valves (RD-AV), which avoid the placement and tying of sutures finally leading
to shorter CPB time. Sutureless valves are biological pericardial prostheses that can be anchored to the
aortic annulus with only three sutures. Three different prostheses has to date, been developed: 3F Enable
(Medtronic, Minneapolis, USA - CE approval withdrawn), Perceval S (Sorin, Saluggia, Italy), and Intuity
Elite (Edward Lifesciences, Irvine, USA). The 3F Enable and Perceval S sutureless prostheses have a nitinol
metal frame and can be deployed and positioned with no sutures in the case of Perceval S valves and only
one suture for the Enable 3F valves. The Intuity rapid deployment aortic valve prosthesis has a cloth-covered
frame and it is implanted through a balloon catheter delivery system that expands the frame once it achieved
the appropriate annular position. Three sutures are required in the case of the Edwards Intuity valve. This
technique may lead to shorter cross-clamp and CPB times, with a smaller amount of related adverse side
effects, shorter in-hospital stay and similar survival rates as compared with conventional AVR. Actually,
the procedure time is operator-dependent and relates to the specific operator learning curve. The prosthesis
is usually landed in an intranular position and this may lead to better hemodynamic performance. RD-AV
need careful patient selection since they need symmetric sinus configuration for adequate fitting in order to
avoid paravalvular leakage and they are not recommended in bicuspid aortic valves. On one hand, it is not
recommended to entirely decalcify the aortic annulus since it can be useful for the anchorage and likewise
it avoids paravalvular leaks; on the other hand, heavily calcified sinutubular junctions may require special
caution in sizing and deployment stages. Risk of stroke still represents an open issue since there are no
specific recommendations regarding anticoagulation regimen after RD-AV implantation and no data are
available on the risk of thrombus formation because of the stent frame and leaflet designs.

Greater morbidities and high-risk profiles on the contemporary patient population have driven the
development of percutaneous TAVI, delivered in a micro-invasive fashion, with no need of CPB neither
cardioplegic induced cardiac arrest. TAVI procedures have dramatically increased worldwide even if this
[11]
data did not result in a decrease of overall SAVR performed compared with prior years . This means that
a consistent part of patients currently treated with TAVI could not beneficiate any surgical options in the
previous years, the so called “pre-TAVI era”. Although it proves to be a good and safe technique in patients
at intermediate - high risk, there are several factors to consider for eligibility as: (1) native annulus size, since
< 18 mm or > 29 mm precludes this procedure; (2) cardiac anatomy, necessary in the choice of implant and
method of delivery; (3) left ventricular outflow size and shape; (4) porcelain aorta or horizontally placed
aortic root, that may complicate a transfemoral delivery; (5) height of coronary artery ostia, to prevent
incidental occlusion of the coronaries; (6) assessment of the peripheral arterial vessels, in terms of diameter,
tortuosities, kinks, preexisting stents, aneurysms or thrombi.

In this setting, it is clear how an appropriate patient selection is the key of success for a good outcome.
Nevertheless, there are still open issues in terms of possible complications that deserve to be considered:
(1) risk of malpositioning, since some models can not be repositioned, retrieved or resheathed; (2) risk of
annular rupture because of oversizing or over dilatation, even if this is an experience-related complication
more than a limit of the technique itself; (3) atrioventricular conduction abnormalities requiring a
[11]
postoperative permanent pacemaker (PPM), this complication ranges between 3%-8% ; (4) paravalvular
leaks; (5) risk of stroke; (6) vascular and bleeding complications; (7) limited durability.

Due to their multifaceted aspects, requiring several different evaluations by several different professionals,
in the last years a new concept has emerged and gained increasing attention in the context of several
procedures like complex coronary interventions and TAVR: the Heart Team.

The “Heart Team” should play a pivotal role in decision making, since most procedures entail a complex
interplay of multispeciality & multi modality skills such as in the case of TAVI. The Heart Team is thus