Complications
The overall complication rate was 59% and included new onset atrial fibrillation (n=65), requisite pacemaker insertion (n=24), and regurgitant flow (encompassing both central aortic regurgitation (n=20) and paravalvular leakage (n=10)). New onset atrioventricular block is more common after sutureless aortic valve replacement (5-17%) than conventional surgical aortic valve replacement (2-4%) (25). Other studies in non-BAV patients with sutureless or rapid-deployment prostheses have shown increased requirement for postoperative pacemaker implantation.17 In a systematic review of 12 studies on the use of sutureless valves including Perceval S, 3F Enable, Trilogy, and Edwards Intuity in patients without BAV, the proportion of patients with postoperative permanent pacemaker insertion, stroke, paravalvular leak, and endocarditis were 5.6%, 1.5%, 3.0%, and 2.2% respectively.26 These findings are comparable to the complications noted in our review for postoperative permanent pacemaker insertion (7.6%), stroke (3.5%), paravalvular leak (3.2%), and endocarditis (0.6%). Meco et al27 suggested that the outward force during balloon dilatation with Perceval sutureless valves on the aortic annulus may cause atrioventricular conduction disorders leading to new onset atrial fibrillation. Additionally, the positioning of the Perceval valve below the aortic annulus may lead to conduction system compression causing atrioventricular block.11 Valve size and BAV asymmetry have also been shown to be associated with heart conductivity (atrial fibrillation, atrioventricular block, and requisite pacemaker insertion) and flow (intraprosthetic aortic regurgitation and paravalvular leakage) problems. Smaller valve sizes have been shown to cause paravalvular leakage in the Edwards Intuity valve and new onset aortic regurgitation in the Perceval valve.11 Larger valve sizes have been shown to increase pacemaker implantation rates in both the Edwards Intuity valve and the Pereceval valve, as well as hemodynamic turbulence in the Perceval valve.10 This can be further complicated by asymmetric expansion of the replacement valve owing to irregular annular space.17 Included studies have demonstrated techniques to address these issues. For Type I BAV, the semicircular annulus and true raphe allows for repair akin to tricuspid aortic valve replacement.20 However, Durdu et al14 reported additional techniques for Type 0 and Type II BAV suggesting that one inter-commissural U-mattress suture was sufficient for elliptical-to-circular remodeling in Type 0 BAVs, but additional mattress sutures and commissural plications may be required in Type II BAVs. The purpose of suture placement is to create otherwise-absent structural integrity that supports symmetric expansion, as well as maintains form amidst fluctuations in pressure consistent with the cardiac cycle.