Surgery · Medical Literature
Mechanical vs. sutureless aortic valve replacement: clinical outcomes and the contribution of preoperative multislice CT.
Abstract
Heart valve disease is a significant cause of morbidity and mortality, and aortic valve replacement (AVR) is a common treatment option. Recently, sutureless biological valves have gained increasing use. This study aimed to evaluate the concordance between preoperative computed tomography-derived annulus measurements and valve sizes implanted during surgery rather than the direct clinical impact of imaging on prosthesis selection. A total of 40 patients with aortic valve stenosis who underwent elective open-heart surgery and preoperative multislice computed tomography between February 20 and May 20, 2024, were included and were randomly allocated into two groups: sutureless biological valve (n = 20) and mechanical valve (n = 20). Data were obtained from patient records and the hospital's data system and analysed statistically. A total of 40 patients were included in the study: 20 received sutureless, rapidly implantable biological valves, and 20 underwent mechanical AVR. The mean age of the cohort was 61.5 ± 9.1 years, with 45% females and 55% males. Compared with the sutureless group, the mechanical valve group had significantly longer cross-clamp (73.5 vs. 53.0 minutes, p < 0.001) and cardiopulmonary bypass times (102 vs. 92 minutes, p = 0.011), as well as smaller sinotubular junction diameters (30.2 vs. 32.3 mm, p = 0.025). In contrast, the sutureless group demonstrated a significantly greater optimal effective orifice area index (1.58 vs. 0.77, p < 0.001). Preoperative computed tomography is a reliable tool for planning AVR. Sutureless biological valves provide shorter cross-clamp and bypass times and favourable haemodynamic performance, whereas mechanical valves are more often associated with smaller valve sizes and longer procedures. Early postoperative outcomes were comparable between groups.
Clinical relevance
Aortic valve stenosis remains a leading cause of valvular morbidity and mortality, and the choice between mechanical and sutureless biological prostheses has direct implications for operative efficiency and hemodynamic outcomes. This study addresses a clinically relevant gap by comparing intraoperative performance metrics and early postoperative outcomes between these two valve strategies in patients undergoing elective open surgical AVR, while also evaluating the utility of preoperative multislice CT (MSCT) annular measurements in prosthesis planning. As sutureless valves gain wider adoption, attending surgeons and cardiologists need contemporary comparative data to guide patient-specific valve selection.
Key findings
1. Cross-clamp time was significantly shorter in the sutureless group compared to the mechanical valve group (53.0 vs. 73.5 minutes; p < 0.001), representing a clinically meaningful reduction in myocardial ischemic burden. 2. Cardiopulmonary bypass time was also significantly shorter in the sutureless group (92 vs. 102 minutes; p = 0.011), suggesting a procedural efficiency advantage. 3. The sutureless group demonstrated a significantly greater optimal effective orifice area index (EOAi) compared to the mechanical valve group (1.58 vs. 0.77; p < 0.001), indicating superior hemodynamic performance and lower likelihood of prosthesis–patient mismatch. 4. The mechanical valve group had significantly smaller sinotubular junction (STJ) diameters on preoperative MSCT compared to the sutureless group (30.2 vs. 32.3 mm; p = 0.025), suggesting that anatomical annular dimensions may influence prosthesis selection. 5. Preoperative MSCT-derived annular measurements demonstrated concordance with implanted valve sizes, supporting its reliability as a planning tool for surgical AVR. 6. Early postoperative outcomes were comparable between the two groups, with no statistically significant differences reported in perioperative mortality or major morbidity in this cohort of 40 patients (n = 20 per arm). NOTE: No confidence intervals or NNT/NNH values were reported in the abstract.
Practice implications
Sutureless biological valves should be preferentially considered in patients where minimizing cross-clamp and cardiopulmonary bypass times is a priority — particularly in high-risk surgical candidates, those with reduced ventricular function, or complex redo cases — given their demonstrated reductions of approximately 20 minutes in clamp time and 10 minutes in bypass time. The markedly superior EOAi in the sutureless group (1.58 vs. 0.77) supports their use in patients at risk for prosthesis–patient mismatch, especially those with smaller aortic roots or high body surface area. Preoperative MSCT annular assessment should be incorporated into routine surgical AVR planning workflows, as its concordance with implanted valve sizes supports its role in optimizing prosthesis selection and anticipating anatomical constraints such as reduced STJ diameter that may favor one valve type over another.