BACKGROUND: Sutureless aortic valve replacement (SuaVR) is a feasible alternative to conventional aortic replacement (SAVR) and transcatheter aortic valve replacement (TAVR). The aim of this study is to compare the effectiveness of the SuAVR versus SAVR, and SuAVR versus TAVR.
METHODS AND RESULTS: We searched MEDLINE and EMBASE from inception to August 2018 for adjusted observational studies evaluating SuAVR, SAVR, and TAVR in adult patients with aortic stenosis. Independently and in duplicate, we performed screening, full-text assessment, risk of bias evaluation using the CLARITY tool. We pooled data using a random-effects model. We evaluated the quality of evidence using the GRADE framework. Of the references, 34 studies including 7979 participants (SuAVR versus SAVR= 6831; SuAVR versus TAVR= 1148) conducted between 2012 and 2018 were included. Overall, studies were judged to be at unclear risk of bias. Compared to SAVR and TAVR, SuAVR was associated with similar postoperative mean transvalvular gradients (mean difference]MD [: –1.00; 95% CI, -2.76 to 0.76; P=0.27) and (MD: 0.50; 95% CI, 0.27 to 1.28; P=0.20) respectively. Compared to TAVR, SuAVR showed a reduction in mortality at 30 days (odds ratio (OR): 0.36; 95% CI, 0.17 to 0.73; P=0.005) and 2 years (OR: 0.39, 95 CI, 0.17 to 0.88; P=0.003). Reduction in mortality did not reach statistical significance in high risk (OR:0.16, 95% CI, 0.02 to 1.35; P=0.09) or intermediate risk patients (OR: 0.76, 95% CI, 0.32 to 1.82, P=0.54). Compared to TAVR, SuAVR showed reduction in mild (OR: 0.09, 95% CI, 0.03 to 0.26, P=0.000) and moderate paravalvular leaks (OR: 0.11, 95% CI, 0.02 to 0.61, P=0.01). Moreover, SuAVR showed significant reduction in acute kidney injury compared to TAVR (OR: 0.50, 95 % CI, 0.27 to 0.91, P=0.02) and comparable reduction to SAVR (OR: 0.89, 95% CI, 0.45 to 1.76, P=0.47). Compared to SAVR, SuAVR showed a similar reduction in mortality at 30 days (OR: 1.01, 95 % CI, 0.72 to 1.42, P=0.93) and at 2 years (OR: 0.99, 95 % CI, 0.43 to 2.30, P= 0.30). These results were rated low-quality evidence using the GRADE framework.
CONCLUSION: While the use of sutureless aortic valves is increasing with similar short and midterm outcomes compared to TAVR and SAVR, the quality of evidence supporting its utilization is low, even with matched patients. Comparative randomized data with long-term follow up is required to elucidate the role of SuAVR.