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.