Clinical efficacy analysis of sutureless aortic valve replacement versus traditional aortic root enlargement for small aortic annulus_Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Authors：

TAN Tong , ZHU Enjun , LI Jinhua , ZHU Junming , WANG Jiangang ,  LAI Yongqiang

Department of Structural Heart Disease Surgery, Beijing Anzhen Hospital, Capital Medical University, Beijing Institute of Heart, Lung and Blood Vessel Diseases, Beijing, 100029, P. R. China;

Corresponding?author：

LAI Yongqiang, Email: laiyongqiang@126.com

Keywords：

Small aortic annulus; sutureless valve; aortic root enlargement; hemodynamics; indexed effective orifice area; perioperative management; lifecycle management

DOI：

10.7507/1007-4848.202602061

Video：

Export PDF Favorites Scan Get Citation

Abstract Full text Figures/Tables Video References Cited by

Objective To analyze the differences in clinical outcomes between sutureless aortic valve replacement (SUAVR) and conventional aortic root enlargement (ARE) techniques in patients with small aortic annulus (SAA). Methods SAA patients undergoing aortic valve replacement at Beijing Anzhen Hospital, Capital Medical University from April 2018 to January 2025 were retrospectively enrolled. Patients were divided into a SUAVR group and an ARE group (including Nicks technique and Manouguian technique) according to surgical approaches. The primary endpoints were postoperative maximum transvalvular pressure gradient and indexed effective orifice area (iEOA). After adjusting for confounding factors using analysis of covariance, the differences in iEOA among the three surgical procedures were compared. Results A total of 56 SAA patients were included, with 26 patients in the SUAVR group and 30 patients in the ARE group (19 patients using Nicks technique and 11 patients using Manouguian technique). The median age of SUAVR group was significantly higher than that of ARE group (62.5 years vs. 57.5 years, P=0.035). Female proportions were 84.6% and 83.3%, respectively. In the ARE group, 73.3% of the patients received mechanical valve implantation and 1 patient died during the perioperative period. Postoperative transvalvular pressure gradient was lower in the SUAVR group compared to that in the ARE group [11.5 (8.3, 23.5) mm Hg vs. 19.0 (16.0, 26.0) mm Hg, P=0.005]. Significant differences existed in iEOA among the three techniques (P<0.001): Nicks group (1.10±0.14) cm²/m², Manouguian group (1.27±0.16) cm²/m², with SUAVR group showing the highest value (1.69±0.18) cm²/m². After adjusting for confounding factors, SUAVR still demonstrated significantly higher adjusted iEOA than both Nicks and Manouguian groups (P<0.001). One patient in the ARE group developed moderate prosthesis-patient mismatch. No permanent pacemaker implantation occurred. Conclusion Among this cohort of SAA patients, those receiving conventional ARE are younger with higher rates of mechanical valve implantation. SUAVR demonstrates favorable perioperative safety while achieving comparable hemodynamic performance to conventional ARE techniques, with significant advantages in iEOA. SUAVR can serve as an effective complementary strategy to traditional ARE techniques in selected SAA patients.

1.	Meguro K, Kumamaru H, Kohsaka S, et al. Transcatheter aortic valve replacement in patients with a small annulus: from the Japanese nationwide registry (J-TVT). Circ J, 2021, 85(7): 967-976.
2.	Okuyama K, Izumo M, Ochiai T, et al. New-generation transcatheter aortic valves in patients with small aortic annuli: comparison of balloon- and self-expandable valves in Asian patients. Circ J, 2020, 84(11): 2015-2022.
3.	茍雨婷, 張純. 超聲心動圖在小瓣環主動脈瓣重度狹窄患者經導管主動脈瓣置換術前評估中的應用概述. 中國醫藥, 2025, 20(3): 453-457.Gou YT, Zhang C. Overview of the application of echocardiography in the preoperative evaluation of transcatheter aortic valve replacement in patients with severe aortic stenosis of the small annulus. China Med, 2025, 20(3): 453-457.
4.	譚桐, 來永強, 王堅剛, 等. Perceval免縫合主動脈瓣的早期臨床療效: 單中心經驗. 中華胸心血管外科雜志, 2025, 41(10): 624-629.Tan T, Lai YQ, Wang JG, et al. Initial clinical experience with the perceval sutureless aortic valve: insights from a single center. Chin J Thorac Cardiovasc Surg, 2025, 41(10): 624-629.
5.	Ashry A, Izzadawela S, Mishra V, et al. Outcomes post-Nick's aortic root enlargement technique: single-center experience. Thorac Cardiovasc Surg, 2022, 10(6): 274-278.
6.	Okuyama H, Hashimoto K, Kurosawa H, et al. Midterm results of Manouguian double valve replacement: comparison with standard double valve replacement. J Thorac Cardiovasc Surg, 2005, 129(4): 869-874.
7.	Herrmann HC. Hemodynamics after TAVR matter. Catheter Cardiovasc Interv, 2023, 102(5): 944-945.
8.	Talapaneni S, Ahmad D, Khandelwal M, et al. Prosthesis-patient mismatch following aortic valve replacement: a comprehensive review. J Clin Med, 2025, 14(24): 8868.
9.	Stefanelli G. Aortic root enlargement: is it still the best surgical tool to avoid patient-prosthesis mismatch after aortic valve replacement? J Card Surg, 2022, 37(10): 3026-3027.
10.	Abdalwahab A, Omari M, Alkhali M. Aortic valve intervention in patients with aortic stenosis and small annulus. Rev Cardiovasc Med, 2025, 26(3): 26738.
11.	Malek AN, Ayyad MAKS, Elkhayat H, et al. Management of small aortic root during aortic valve replacement. Egypt Cardiothorac Surg, 2020, 2(1): 1-7.
12.	Colarossi G, Migliorini F, Becker M, et al. Conventional prostheses versus sutureless Perceval for aortic valve replacement: a meta-analysis. Ann Thorac Cardiovasc Surg, 2023, 29(3): 107-124.
13.	Berretta P, Andreas M, Carrel TP, et al. Minimally invasive aortic valve replacement with sutureless and rapid deployment valves: a report from an international registry (Sutureless and Rapid Deployment International Registry). Eur J Cardiothorac Surg, 2019, 56(4): 793-799.
14.	Okiljevic B, Raickovic T, Zivkovic I, et al. Right anterior thoracotomy vs. upper hemisternotomy for aortic valve replacement with Perceval S: is there a difference? Front Cardiovasc Med, 2024, 11: 1369204.
15.	楊鵬, 謝毅, 王晨昊, 等. Perceval免縫合主動脈瓣在胸骨上段/右側肋間微創小切口主動脈瓣置換術中的應用. 中國胸心血管外科臨床雜志, 2024, 31(3): 439-445.Yang P, Xie Y, Wang CH, et al. Minimally invasive aortic valve replacement with Perceval sutureless aortic bioprosthesis through upper ministernotomy or right anterior thoracotomy. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(3): 439-445.
16.	Sakata T, de la Pena C, Ohira S. Rapid-deployment aortic valve replacement: patient selection and special considerations. Vasc Health Risk Manag, 2023, 19: 169-180.
17.	Tasca G, Vismara R, Mangini A, et al. Comparison of the performance of a sutureless bioprosthesis with two pericardial stented valves on small annuli: an in vitro study. Ann Thorac Surg, 2017, 103(1): 139-144.
18.	Dedeilias P, Baikoussis NG, Prappa E, et al. Aortic valve replacement in elderly with small aortic root and low body surface area; the Perceval S valve and its impact in effective orifice area. J Cardiothorac Surg, 2016, 11(1): 54.
19.	Bacco LD, D'Alonzo M, Eusani MD, et al. Sutureless aortic valve replacement vs. transcatheter aortic valve implantation in patients with small aortic annulus: clinical and hemodynamic outcomes from a multi-institutional study. Braz J Cardiovasc Surg, 2024, 39(4): e20230155.
20.	Fazmin IT, Ali JM. Prosthesis-patient mismatch and aortic root enlargement: indications, techniques and outcomes. J Cardiovasc Dev Dis, 2023, 10(9): 373.
21.	Yang B, Ghita C, Makkinejad A, et al. Early outcomes of the Y-incision technique to enlarge the aortic annulus 3 to 4 valve sizes. J Thorac Cardiovasc Surg, 2024, 167(4): 1196-1205. e2.
22.	Makkinejad A, Hua J, Hassler KR, et al. Comparison of the short-term outcomes between Y-incision aortic annular enlargement and traditional aortic annular enlargement techniques. Ann Cardiothorac Surg, 2024, 13(3): 255-265.
23.	Agarwal R, Arnav A, Ranjan A, et al. Sutureless valves versus aortic root enlargement for aortic valve replacement in small aortic annulus: a systematic review and pooled analysis. Asian Cardiovasc Thorac Ann, 2023, 31(6): 524-532.
24.	Glauber M, Di Bacco L, Cuenca J, et al. Minimally invasive aortic valve replacement with sutureless valves: results from an international prospective registry. Innovations, 2020, 15(2): 120-130.
25.	Ensminger S, Fujita B, Bauer T, et al. Rapid deployment versus conventional bioprosthetic valve replacement for aortic stenosis. J Am Coll Cardiol, 2018, 71(13): 1417-1428.
26.	Toledano B, Bisbal F, Camara ML, et al. Incidence and predictors of new-onset atrioventricular block requiring pacemaker implantation after sutureless aortic valve replacement. Interact Cardiovasc Thorac Surg, 2016, 23(6): 861-868.

1. Meguro K, Kumamaru H, Kohsaka S, et al. Transcatheter aortic valve replacement in patients with a small annulus: from the Japanese nationwide registry (J-TVT). Circ J, 2021, 85(7): 967-976.
2. Okuyama K, Izumo M, Ochiai T, et al. New-generation transcatheter aortic valves in patients with small aortic annuli: comparison of balloon- and self-expandable valves in Asian patients. Circ J, 2020, 84(11): 2015-2022.
3. 茍雨婷, 張純. 超聲心動圖在小瓣環主動脈瓣重度狹窄患者經導管主動脈瓣置換術前評估中的應用概述. 中國醫藥, 2025, 20(3): 453-457.Gou YT, Zhang C. Overview of the application of echocardiography in the preoperative evaluation of transcatheter aortic valve replacement in patients with severe aortic stenosis of the small annulus. China Med, 2025, 20(3): 453-457.
4. 譚桐, 來永強, 王堅剛, 等. Perceval免縫合主動脈瓣的早期臨床療效: 單中心經驗. 中華胸心血管外科雜志, 2025, 41(10): 624-629.Tan T, Lai YQ, Wang JG, et al. Initial clinical experience with the perceval sutureless aortic valve: insights from a single center. Chin J Thorac Cardiovasc Surg, 2025, 41(10): 624-629.
5. Ashry A, Izzadawela S, Mishra V, et al. Outcomes post-Nick's aortic root enlargement technique: single-center experience. Thorac Cardiovasc Surg, 2022, 10(6): 274-278.
6. Okuyama H, Hashimoto K, Kurosawa H, et al. Midterm results of Manouguian double valve replacement: comparison with standard double valve replacement. J Thorac Cardiovasc Surg, 2005, 129(4): 869-874.
7. Herrmann HC. Hemodynamics after TAVR matter. Catheter Cardiovasc Interv, 2023, 102(5): 944-945.
8. Talapaneni S, Ahmad D, Khandelwal M, et al. Prosthesis-patient mismatch following aortic valve replacement: a comprehensive review. J Clin Med, 2025, 14(24): 8868.
9. Stefanelli G. Aortic root enlargement: is it still the best surgical tool to avoid patient-prosthesis mismatch after aortic valve replacement? J Card Surg, 2022, 37(10): 3026-3027.
10. Abdalwahab A, Omari M, Alkhali M. Aortic valve intervention in patients with aortic stenosis and small annulus. Rev Cardiovasc Med, 2025, 26(3): 26738.
11. Malek AN, Ayyad MAKS, Elkhayat H, et al. Management of small aortic root during aortic valve replacement. Egypt Cardiothorac Surg, 2020, 2(1): 1-7.
12. Colarossi G, Migliorini F, Becker M, et al. Conventional prostheses versus sutureless Perceval for aortic valve replacement: a meta-analysis. Ann Thorac Cardiovasc Surg, 2023, 29(3): 107-124.
13. Berretta P, Andreas M, Carrel TP, et al. Minimally invasive aortic valve replacement with sutureless and rapid deployment valves: a report from an international registry (Sutureless and Rapid Deployment International Registry). Eur J Cardiothorac Surg, 2019, 56(4): 793-799.
14. Okiljevic B, Raickovic T, Zivkovic I, et al. Right anterior thoracotomy vs. upper hemisternotomy for aortic valve replacement with Perceval S: is there a difference? Front Cardiovasc Med, 2024, 11: 1369204.
15. 楊鵬, 謝毅, 王晨昊, 等. Perceval免縫合主動脈瓣在胸骨上段/右側肋間微創小切口主動脈瓣置換術中的應用. 中國胸心血管外科臨床雜志, 2024, 31(3): 439-445.Yang P, Xie Y, Wang CH, et al. Minimally invasive aortic valve replacement with Perceval sutureless aortic bioprosthesis through upper ministernotomy or right anterior thoracotomy. Chin J Clin Thorac Cardiovasc Surg, 2024, 31(3): 439-445.
16. Sakata T, de la Pena C, Ohira S. Rapid-deployment aortic valve replacement: patient selection and special considerations. Vasc Health Risk Manag, 2023, 19: 169-180.
17. Tasca G, Vismara R, Mangini A, et al. Comparison of the performance of a sutureless bioprosthesis with two pericardial stented valves on small annuli: an in vitro study. Ann Thorac Surg, 2017, 103(1): 139-144.
18. Dedeilias P, Baikoussis NG, Prappa E, et al. Aortic valve replacement in elderly with small aortic root and low body surface area; the Perceval S valve and its impact in effective orifice area. J Cardiothorac Surg, 2016, 11(1): 54.
19. Bacco LD, D'Alonzo M, Eusani MD, et al. Sutureless aortic valve replacement vs. transcatheter aortic valve implantation in patients with small aortic annulus: clinical and hemodynamic outcomes from a multi-institutional study. Braz J Cardiovasc Surg, 2024, 39(4): e20230155.
20. Fazmin IT, Ali JM. Prosthesis-patient mismatch and aortic root enlargement: indications, techniques and outcomes. J Cardiovasc Dev Dis, 2023, 10(9): 373.
21. Yang B, Ghita C, Makkinejad A, et al. Early outcomes of the Y-incision technique to enlarge the aortic annulus 3 to 4 valve sizes. J Thorac Cardiovasc Surg, 2024, 167(4): 1196-1205. e2.
22. Makkinejad A, Hua J, Hassler KR, et al. Comparison of the short-term outcomes between Y-incision aortic annular enlargement and traditional aortic annular enlargement techniques. Ann Cardiothorac Surg, 2024, 13(3): 255-265.
23. Agarwal R, Arnav A, Ranjan A, et al. Sutureless valves versus aortic root enlargement for aortic valve replacement in small aortic annulus: a systematic review and pooled analysis. Asian Cardiovasc Thorac Ann, 2023, 31(6): 524-532.
24. Glauber M, Di Bacco L, Cuenca J, et al. Minimally invasive aortic valve replacement with sutureless valves: results from an international prospective registry. Innovations, 2020, 15(2): 120-130.
25. Ensminger S, Fujita B, Bauer T, et al. Rapid deployment versus conventional bioprosthetic valve replacement for aortic stenosis. J Am Coll Cardiol, 2018, 71(13): 1417-1428.
26. Toledano B, Bisbal F, Camara ML, et al. Incidence and predictors of new-onset atrioventricular block requiring pacemaker implantation after sutureless aortic valve replacement. Interact Cardiovasc Thorac Surg, 2016, 23(6): 861-868.

Chinese Journal of Clinical Thoracic and Cardiovascular Surgery

Latest ArticlesClinical efficacy analysis of sutureless aortic valve replacement versus traditional aortic root enlargement for small aortic annulus

Abstract Full text Figures/Tables Video References Cited by

Format

Content