Background: The management of patients with aortic valve pathologies can sometimes fall into a “gray zone”, where the optimal treatment approach is not straightforward. The comparative benefits of sutureless aortic valve replacement (SUAVR) using the Perceval bioprosthesis versus transcatheter aortic valve implantation (TAVI) for the “gray zone” of aortic valve replacement procedures remain a topic of debate. To further explore this issue, we conducted a study with pairwise, single-arm, and Kaplan–Meier-based meta-analyses to compare the outcomes of SUAVR with the Perceval bioprosthesis versus TAVI, as well as to evaluate the efficacy, safety, and durability of SUAVR with the Perceval bioprosthesis over mid-term and long-term follow-up periods. Methods: The PubMed, PubMed Central, OVID Medline, Cochrane Library, Embase, and Web of Science databases were systematically searched. All study types were included, except study protocols and animal studies, without time restrictions. The final search was carried out in May 2024. Results: No statistically significant differences were observed in permanent pacemaker implantation (PPI) rates between the two groups. SUAVR showed a lower incidence of new-onset myocardial infarction but was associated with higher rates of new-onset atrial fibrillation and major bleeding. TAVI had higher rates of left bundle branch block and major vascular complications. Conclusions: Our findings show that SUAVR has a lower incidence of complications and a favorable mid-term overall survival compared to TAVI. SUAVR has more advantages compared to TAVI and can be considered a valuable and promising option for the “grey zone” of aortic valve pathologies.

Background/Objectives: Over the past two decades, significant advancements in mitral valve surgery have focused on minimally invasive techniques. Some surgeons consider obesity as a relative contraindication for minimally invasive mitral valve surgery (MIMVS). The aim of this study is to evaluate whether the specific characteristics of obese patients contribute to increased surgical complexity and whether this, in turn, leads to worse clinical outcomes compared to non-obese patients. Furthermore, we aim to explore whether these findings could substantiate the consideration of limiting this treatment option for obese patients. We investigated the outcomes of MIMVS in obese and non-obese patients at a high-volume center in Germany staffed by an experienced surgical team well-versed in perioperative management. Methods: A total of 934 MIMVS were performed in our high-volume center in Germany from 2011 to 2023. Of these, 196 patients had a BMI of 30 or higher (obese group), while 738 patients had a BMI below 30 (non-obese group), all of whom underwent MIMVS by right minithoracotomy. Demographic information, echocardiographic assessments, surgical data, and clinical outcome parameters were collected for all patients. Results: There was no significant difference in in-hospital, 30-day, and late mortality between groups (obese vs. non-obese: 6 [3.0%] vs. 14 [1.8%], p = 0.40; 6 [3.0%] vs. 14 [1.8%], p = 0.40; 13 [6.6%] vs. 39 [5.3%], p = 0.48, respectively). Respiratory insufficiency and arrhythmia occurred more frequently in the obese group (obese vs. non-obese: 25 [12.7%] vs. 35 [4.7%], p < 0.001; 35 [17.8%] vs. 77 [10.4%], p = 0.006). Conclusions: Obesity was not associated with increased early or late mortality in patients undergoing MIMVS. However, obese patients experienced higher incidences of postoperative complications, including respiratory insufficiency, arrhythmias, delirium, and wound dehiscence. Nonetheless, a multivariate logistic regression analysis indicated that obesity itself does not contraindicate MIMVS and should not be viewed as a barrier to offering this minimally invasive approach to obese patients.

Background/Objectives: The optimal choice of cardioplegia solution in minimally invasive cardiac surgeries (MICS) remains debated, as prolonged myocardial protection is essential to avoid interruptions to the surgical flow, which can prolong aortic cross-clamp time and cardiopulmonary bypass time, especially in the constrained surgical field. We conducted a network meta-analysis to evaluate the safety and efficacy of the del Nido (DN), histidine-tryptophan-ketoglutarate (HTK), blood cardioplegia (BC), and St. Thomas’ (STH) solutions in MICS. Methods: Medical electronic databases were thoroughly searched without time restrictions, including all types of studies except for study protocols and animal research. The final search was completed in June 2024. Subsequently, a network meta-regression was performed on both primary and secondary endpoints, utilizing R (The R Foundation for Statistical Computing, version 3.6.2) for the analysis. Meta-analyses were carried out using Review Manager software. Results: A total of 15 studies, enrolling 2282 patients, were included in the analysis. None of the comparisons showed statistically significant differences in in-hospital mortality between the four cardioplegia solutions (BC vs. HTK, OR: 3.21, 95% CI: 0.13–80.84; DN vs. HTK, OR: 1.42, 95% CI: 0.28–7.23; STH vs. HTK, OR: 1.25, 95% CI: 0.19–8.20). Conclusions: In this network meta-analysis of cardioplegia solutions in MICS, no significant differences were observed in major clinical outcomes across the solutions. Cardioplegia solutions that provide long-lasting myocardial protection with a single dose, such as DN and HTK, were found to be safely applied in MICS. DN was associated with shorter CPB times and HTK was associated with shorter hospital stays, though these differences may not have clinical implications.

Background: Early bioprosthetic valve dysfunction (BVD) due to pannus formation is uncommon in elderly patients, and only a limited number of cases have been reported. Case summary: An 84-year-old man presented with exertional dyspnoea 3 years after surgical aortic valve replacement (SAVR) with a 19 mm Epic™ valve (Abbott, Santa Clara, CA, USA). Transthoracic echocardiography demonstrated progressive BVD, and cardiac computed tomography (CT) revealed sub-aortic pannus formation. Re-operative SAVR was performed using a 19 mm INSPIRIS RESILIA® valve (Edwards Lifesciences, Irvine, CA, USA), and pathological examination confirmed valve leaflet deformation caused by pannus overgrowth. At the 18-month follow-up, the patient exhibited favourable progress, with no indications of BVD or pannus recurrence. Discussion: This case highlights the importance of recognizing early pannus formation as a cause of BVD, even in elderly patients. Early detection of BVD based on clinical symptoms and echocardiography is vital to allow timely surgical intervention before the deterioration of cardiac function. Cardiac CT helps to differentiate pannus from thrombus formation and guide treatment decisions.