Management of small aortic annulus in the era of sutureless valves: A comparative study among different biological options

Objective: Aortic valve replacement ( AVR) in patients with a small aortic annulus is a challenging problem. The objective of this study was to compare 4 surgical approaches in terms of hemodynamics and perioperative outcomes. Methods: A retrospective single-center study included 351 consecutive patients with a small aortic annulus ( <= 21 mm) who underwent aortic valve surgery between January 2007 and December 2014. Surgical techniques included standard AVR in 259 ( 74%) patients, aortic root enlargement in 20 ( 6%), implantation of a stentless bioprosthesis in 23 ( 6%), and sutureless AVR in 49 ( 13%). Results: Three hundred and eleven ( 89%) patients were female. The mean Logistic EuroSCORE II varied significantly among the groups and ranged from 6.5% +/- 5.4% in the standard AVR group to 9.2% +/- 4.7% in the stentless group. Early mortality occurred in 26 ( 7%) patients. Patients in the stentless group had the lowest aortic valve mean gradients on predischarge transthoracic echocardiography ( 10.9 +/- 6.2 mm Hg; P <.001). In the stented group, the Trifecta prosthesis displayed the lowest postoperative mean transaortic gradient ( 10.3 +/- 3.6; P<. 001) with no severe prosthesis-patient mismatch. Postoperative gradients of the sutureless group were comparable with stented prostheses. Conclusions: In our study, stentless AVR and Trifecta bioprostheses had the best hemodynamic outcomes. The Perceval sutureless prosthesis provides reasonable hemodynamic performance and is a safe alternative.