The following are key points to remember from a state-of-the-art review on sutureless valves, a “wireless” option for patients with aortic valve disease:

1. “Sutureless” or “rapid deployment” valves (collectively referred to as sutureless valves) are a novel type of prosthetic valve for aortic valve replacement (AVR) that avoids or minimizes the need for anchoring sutures, with the goals of simplified implantation and reduced cardiopulmonary bypass and operative times. Two devices currently are available: Perceval (Corcym; a truly “sutureless” device) and Intuity (Edwards Lifesciences; a rapid-deployment device utilizing three sutures). Hypothetical advantages of sutureless AVR include more rapid deployment during a prolonged procedure (multiple valve surgeries and/or concomitant procedures) or difficult access to the annulus (calcified root or homograft, redo operation, fragile aortic wall).
2. Thirty-day and long-term mortality:
   • There are limited data directly comparing 30-day and long-term mortality between patients undergoing sutureless AVR with those undergoing conventional surgical AVR (SAVR) or transcatheter AVR (TAVR).
   • A pooled cumulative analysis of observational and randomized trials comparing SAVR with sutureless AVR showed no difference in mortality at 1 year (odds ratio [OR], 1.01; 95% confidence interval [CI], 0.87-1.16; p = 0.97).
   • A pooled cumulative analysis of observational propensity-matched studies comparing TAVR and sutureless AVR did not show a statistically significant difference between groups in 30-day mortality (OR, 0.59; 95% CI, 0.21-1.59; p = 0.29).
   • Some studies have reported lower transvalvular gradients and lower incidence of mild aortic regurgitation (AR) associated with the rapid-deployment valve, with lower cross-clamp and bypass times and shorter length of stay associated with the sutureless device. A systematic analysis showed no difference in 1-year mortality between the two devices.
3. Paravalvular leak (PVL): Variably equivalent or higher rates of PVL have been reported after sutureless AVR compared to conventional SAVR; the average reported incidence of PVL is lower after sutureless AVR compared to TAVR. The rate of PVL after sutureless AVR is associated with operator experience and might decrease in the future.
4. Stroke: Several trials have reported similar rates of stroke after sutureless AVR compared to conventional SAVR. Rates of stroke have been variably reported as lower or similar after sutureless AVR compared to TAVR.
5. Permanent pacemaker implantation: The rate of permanent pacemaker implantation probably is higher after sutureless AVR compared to conventional SAVR but lower after sutureless AVR compared to TAVR.
6. Hemodynamics and prosthesis-patient mismatch (PPM):
   • Several studies have shown lower gradients and a lower rate of PPM after sutureless AVR compared to conventional SAVR.
   • One study reported higher effective orifice area and a lower rate of PPM after TAVR compared to sutureless AVR.
7. The proposed main advantage of reduced ischemic time associated with the use of sutureless AVR compared to conventional SAVR is not yet supported by conclusive evidence that their use is associated with improved mortality or morbidity.
8. The authors propose an algorithm for patients with severe aortic stenosis to help guide decisions between surgical AVR (conventional SAVR or sutureless AVR) and TAVR that incorporates patient age, perioperative risk assessment, the presence of frailty or other comorbidities, need for a concomitant procedure, and anatomical characteristics pertinent to TAVR versus conventional SAVR or sutureless AVR.
9. Specific anatomical considerations pertinent to decisions between conventional SAVR and sutureless AVR include:
   • In favor of sutureless AVR: High-risk patient, redo surgery, difficult access, calcified root/ascending aorta or prior homograft, or concomitant procedures.
   • In favor of conventional SAVR: bicuspid aortic valve, annulus >27 mm or <19 mm requiring enlargement, sinotubular junction >40 mm, or high risk of atrioventricular (AV) block (pre-existing AV block, right bundle branch block, severe calcification of the annulus or interventricular septum).
10. There is not yet consensus regarding the clinical role of sutureless AVR, presumably related to complex factors that include the predominantly observational nature of data for sutureless AVR as well as surgeon experience and partiality.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Valvular Heart Disease, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Aortic Valve Disease, Heart Valve Prosthesis, Transcatheter Aortic Valve Replacement

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