In the field of aortic valve surgery, no absolute truth exists regarding which type of prosthesis may prove most durable and resilient, especially considering outcomes like zero endocarditis or minimized morbidity. Given the absence of an ideal substitute, the pursuit of the best option must remain our guiding principle. 

Aortic stenosis is the most prevalent valvular heart disease, accounting for up to 12% of cases in individuals over 75 years, with approximately 4% meeting criteria for severe disease. The primary etiology is degenerative, particularly in developed, aging countries like Spain. 

Aortic valve replacement (AVR) remains the sole therapy with proven impact on the natural history of aortic stenosis. Although surgical AVR has long been the gold standard, transcatheter aortic valve implantation (TAVI) has emerged as the treatment of choice for inoperable and high-risk patients and as a viable alternative for those at intermediate risk. Recently, sutureless AVR (SU-AVR) has been introduced as another alternative to conventional AVR. The Perceval S bioprosthesis (Corcym Srl, Sallugia, Italy) is the most widely used sutureless aortic bioprosthesis, with over 10000 implants globally. It has demonstrated a reduction in operative times and excellent medium- to long-term outcomes in terms of morbidity and mortality, particularly in challenging cases (small aortic roots or annuli, reoperations, etc.), as discussed in previous blog entries. 

Some of the longest series, such as that by Dr. Meuris, now exceed 12 years of durability with favorable outcomes in terms of freedom from reintervention or valve-in-valve implantation. 

Sutureless prostheses and TAVI are complementary procedures within the therapeutic arsenal for managing high-risk aortic valve disease patients. In the case of sutureless prostheses, they have also contributed significantly to advances in minimally invasive surgery, which clearly offers not only aesthetic benefits but also a reduction in postoperative morbidity (hospital and ICU stays, intubation duration, etc.). 

The increase in early diagnosis through health education programs beyond tertiary care has already borne fruit in the diagnosis of aortic disease, with a corresponding rise in the number of patients referred for either surgical treatment or TAVI. Therefore, caution is warranted when interpreting study outcomes. For example, major trials such as AVATAR demonstrate the superiority of surgical treatment over conservative management in terms of morbidity and mortality. However, the favorable results of EARLY TAVR and EVOLVED should be critically evaluated for not emphasizing two crucial factors: 

• Evaluation of percutaneous treatment of aortic stenosis versus conservative management. 

• Consideration of cardinal factors such as patient age or valve anatomy, given that patients with bicuspid valves experience poorer durability and complication rates (pacemaker need, embolic events) in this profile. Approximately one month ago, and as recently published on our blog, the AUTHEARTVISIT study offered a realistic view of TAVI survival, consolidating one of the largest published experiences to date. It reinforces the need for critical evaluation of observational versus multicenter studies, highlighting TAVI’s survival reality and reinforcing the benefits of surgical treatment. 

Consequently, our focus should be on enhancing surgical processes: minimally invasive surgery with sutureless prostheses, as well as improved patient preparation and recovery protocols (e.g., implementation of RICC pathways), to optimize short-term outcomes, hospital stays, and initial morbidity associated with surgery. 

Despite the advent of minimally invasive surgery in Spain in the early 1990s, the rise and establishment of minimally invasive programs have been driven by SU-AVR, simplifying procedures and reducing operative times. Numerous individual studies and meta-analyses highlight aesthetic and recovery benefits, along with reduced transfusion needs, renal insufficiency, etc. Relative contraindications for minimally invasive surgery include reoperations, emergency surgery, or severe thoracic deformities, yet the convenience of minimally invasive approaches has led to their consideration in a growing number of groups for isolated aortic valve surgery and aortic root or ascending aorta surgery. 

The emergence of robotic surgery has also impacted minimally invasive surgery in recent years. However, it has yet to achieve the necessary weight to establish it as the gold standard, being technically demanding and selectively adopted by specific groups. Thus, minimally invasive surgery, with its reproducibility via third-fourth intercostal J-shaped, inverted T, or anterior right second intercostal space incisions, or even periareolar approaches, must be recognized as the gold standard for isolated AVR. 

Despite the considerable number of us performing minimally invasive aortic procedures, our society lacks comprehensive “evangelization” and dissemination of our outcomes. We must emphasize observational studies and group experience descriptions, particularly publishing results in aortic surgery. SU-AVR in minimally invasive settings allows us to compete at the same level in high- and moderate-risk surgical scenarios as TAVI. 

Emphasis should be placed on the durability of sutureless prostheses versus TAVI, with studies showing a 92% freedom from reintervention rate in younger patients (under 75 years), as well as the impact of pacemaker implantation on quality of life, which remains significantly higher in TAVI (8-30% in some series) compared to 3-5% in SU-AVR. 

In conclusion, offering the best therapeutic option in our commitment to patient care is essential in our quest for excellence. We must support minimally invasive techniques with sutureless prostheses as an ideal therapeutic option in aortic valve disease for patients over 70. The future must be shaped by continuous learning, fitting for a modern, evolving medical field. Our collaboration with hemodynamics specialists should be diplomatic and equal, sharing a unified goal: to pursue the best therapeutic option for our patients. Only by adapting to new strategies (expanding minimally invasive surgery) and learning through continuous feedback can we overcome the hesitation seen in some groups where TAVI activity is more aggressive. And certainly, promoting favorable outcomes in terms of morbidity and durability of AVR is paramount. Observational and longitudinal studies bear scientific weight, potentially exceeding that of randomized studies, in an era where Bayesian statistics is gaining prominence over probabilistic methods. 

REFERENCE:

1. Banovic M, Putnik S, Penicka M, Doros G, Deja MA, Kockova R, et al.; AVATAR Trial Investigators*. Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: The AVATAR Trial. Circulation. 2022 Mar;145(9):648-658. doi: 10.1161/CIRCULATIONAHA.121.057639.
2. Taniguchi T, Morimoto T, Shiomi H, Ando K, Kanamori N, Murata K, et al.; CURRENT AS Registry Investigators. Initial Surgical Versus Conservative Strategies in Patients With Asymptomatic Severe Aortic Stenosis. J Am Coll Cardiol. 2015 Dec 29;66(25):2827-2838. doi: 10.1016/j.jacc.2015.10.001.
3. Kang DH, Park SJ, Lee SA, Lee S, Kim DH, Kim HK, Yun SC, Hong GR, Song JM, Chung CH, Song JK, Lee JW, Park SW. Early Surgery or Conservative Care for Asymptomatic Aortic Stenosis. N Engl J Med. 2020 Jan 9;382(2):111-119. doi: 10.1056/NEJMoa1912846.
4. Banovic M, Putnik S, Iung B, Bartunek J. Response by Banovic et al to Letter Regarding Article, “Aortic Valve Replacement Versus Conservative Treatment in Asymptomatic Severe Aortic Stenosis: The AVATAR Trial”. Circulation. 2022 Aug 9;146(6):e48-e49. doi: 10.1161/CIRCULATIONAHA.122.060918.
5. Boti BR, Hindori VG, Schade EL, Kougioumtzoglou AM, Verbeek EC, Driessen-Waaijer A, et al. Minimal invasive aortic valve replacement: associations of radiological assessments with procedure complexity. J Cardiothorac Surg. 2019 Oct 12;14(1):173. doi: 10.1186/s13019-019-0997-5.