Sutureless aortic valve replacement for aortic stenosis

Evidence-based recommendations on sutureless aortic valve replacement for aortic stenosis in adults. This involves removing the narrowed aortic valve and replacing it with an artificial valve that holds itself in place.

# Recommendations
Current evidence on the safety and efficacy of sutureless aortic valve replacement for aortic stenosis is adequate to support the use of this procedure, provided that standard arrangements are in place for clinical governance, consent and audit. Find out what standard arrangements mean on the NICE interventional procedures guidance page.
Patient selection should be done by a multidisciplinary team, including cardiologists and cardiac surgeons.
Specific training is important for this procedure and surgeons should do their initial procedures with an experienced mentor.
Clinicians should enter details about all patients having sutureless aortic valve replacement for aortic stenosis onto the UK National Institute for Cardiovascular Outcomes Research database.# The condition, current treatments and procedure

# The condition
Aortic stenosis causes impaired blood flow out of the heart and is usually progressive. The increased cardiac workload leads to left ventricular hypertrophy, arrhythmias, and may lead to lifethreatening heart failure. Symptoms of aortic stenosis typically include shortness of breath and chest pain on exertion.

# Current treatments
Conventional treatment for patients with severe symptomatic aortic stenosis is surgical aortic valve replacement. Surgical aortic valve replacement may not be suitable for some patients because of medical comorbidities or technical considerations, such as a calcified aorta or scarring from previous cardiac surgery. Continued medical care may be the only option for some patients. Transcatheter aortic valve implantation (TAVI) for aortic stenosis is an alternative for patients for whom surgery is unsuitable, but it does not allow for concomitant coronary artery bypass grafting.

# The procedure
Sutureless aortic valve replacement (SUAVR) for aortic stenosis is an alternative to conventional surgical aortic valve replacement. The potential benefits of the procedure are that the diseased valve is removed, combined pathologies of the aortic valve and the coronary arteries can be treated, as they can in conventional surgical aortic valve replacement. Also, the procedure may be quicker because the valve does not need to be sewn in, which reduces cardiopulmonary and aortic crossclamp times.
With the patient under general anaesthesia, access to the heart is usually made through a full- or ministernotomy, or right anterior thoracotomy. Once cardiopulmonary bypass and cardioplegia are established, the diseased aortic valve is accessed and removed through a cut in the aorta. Bulky calcifications around the native aortic annulus are removed to achieve a smooth round annulus for valve implantation. The valve prosthesis with selfexpanding or balloon expanding frame, loaded into a special delivery device, is deployed into the native annulus. Once in position the valve is released. The exact deployment method varies between the different devices available for this procedure and with some devices; one or more temporary guiding or securing sutures may be used. Balloon dilatation of the new valve may be used to maximise the area of contact between the prosthesis and the aortic annulus. Once the valve is deployed, the delivery system is removed and the aortotomy is closed. All of the devices used in this procedure contain material derived from animal sources.
This procedure is sometimes described as sutureless aortic valve replacement and sometimes as rapid deployment aortic valve replacement.