Sutureless aortic valves: timing, technique, and evidence

This review synthesizes contemporary evidence for sutureless aortic valve replacement (SuAVR). It focuses on indications, imaging-guided sizing, operative technique, outcomes, and complications to clarify where SuAVR meaningfully complements or substitutes conventional surgical aortic valve replacement and transcatheter aortic valve implantation.

Modern studies show SuAVR consistently shortens cardiopulmonary bypass and cross-clamp times by 25-50%, produces low discharge gradients and larger effective orifice areas, and is particularly advantageous in elderly patients, small annuli, redo operations, and concomitant procedures. Routine multidetector-row computed tomography perimeter sizing and meticulous annular decalcification have reduced clinically relevant paravalvular leak to low single digits, whereas higher implantation and conservative ballooning have lowered permanent pacemaker implantation rates toward single digits. Mid-term durability is encouraging, with 95-97% freedom from structural valve deterioration and 94-97% freedom from reintervention at 5  years. Conduction-system injury, transient thrombocytopenia, and residual pacemaker risk remain the principal trade-offs.

With Heart-Team selection and standardized computed tomography-first workflows and implant technique, SuAVR is a valuable surgical option that expands minimally invasive and complex surgical candidacy. Definitive adoption requires randomized long-term comparisons and standardized pacemaker-avoidance protocols.