\documentclass[10pt]{article}

\usepackage{fullpage}
\usepackage{setspace}
\usepackage{parskip}
\usepackage{titlesec}
\usepackage[section]{placeins}
\usepackage{xcolor}
\usepackage{breakcites}
\usepackage{lineno}
\usepackage{hyphenat}





\PassOptionsToPackage{hyphens}{url}
\usepackage[colorlinks = true,
            linkcolor = blue,
            urlcolor  = blue,
            citecolor = blue,
            anchorcolor = blue]{hyperref}
\usepackage{etoolbox}
\makeatletter
\patchcmd\@combinedblfloats{\box\@outputbox}{\unvbox\@outputbox}{}{%
  \errmessage{\noexpand\@combinedblfloats could not be patched}%
}%
\makeatother


\usepackage{natbib}




\renewenvironment{abstract}
  {{\bfseries\noindent{\abstractname}\par\nobreak}\footnotesize}
  {\bigskip}

\titlespacing{\section}{0pt}{*3}{*1}
\titlespacing{\subsection}{0pt}{*2}{*0.5}
\titlespacing{\subsubsection}{0pt}{*1.5}{0pt}


\usepackage{authblk}


\usepackage{graphicx}
\usepackage[space]{grffile}
\usepackage{latexsym}
\usepackage{textcomp}
\usepackage{longtable}
\usepackage{tabulary}
\usepackage{booktabs,array,multirow}
\usepackage{amsfonts,amsmath,amssymb}
\providecommand\citet{\cite}
\providecommand\citep{\cite}
\providecommand\citealt{\cite}
% You can conditionalize code for latexml or normal latex using this.
\newif\iflatexml\latexmlfalse
\providecommand{\tightlist}{\setlength{\itemsep}{0pt}\setlength{\parskip}{0pt}}%

\AtBeginDocument{\DeclareGraphicsExtensions{.pdf,.PDF,.eps,.EPS,.png,.PNG,.tif,.TIF,.jpg,.JPG,.jpeg,.JPEG}}

\usepackage[utf8]{inputenc}
\usepackage[ngerman,greek,english]{babel}



\usepackage{float}








\begin{document}

\title{Perceval Sutureless Valve-A limbo concept or a future trial}



\author[1]{Ajeet Bana}%
\author[1]{Saurabh Jaiswal}%
\author[1]{Vimal Yadav}%
\author[1]{Mukta Tiwari}%
\author[1]{Anuj Sangal}%
\affil[1]{Eternal Heart Care Centre and Research Institute}%


\vspace{-1em}



  
  \date{May 24, 2024}


\begingroup
\let\center\flushleft
\let\endcenter\endflushleft
\maketitle
\endgroup





\selectlanguage{english}
\begin{abstract}
Objective Aortic stenosis has traditionally been addressed with surgical
aortic valve replacement with a stented prosthesis. Several technologies
have emerged as an alternative treatment method for aortic valve
disease. Among them, Perceval Sutureless valve has been used in clinical
practice for more than a decade. The aim of this study was to evaluate
the results of Perceval Sutureless valve from single centre in Indian
population. Method Between April 2018 to December 2021, 30 elective
patients underwent aortic valve replacement with the Perceval Sutureless
valve. 19 patients had isolated AVR and 11 patients underwent AVR +
Coronary artery bypass grafting (CABG) with average grafts 2.1 \selectlanguage{ngerman}± 0.8.
Majority of isolated AVR, 12 of 19, were done by minimally invasive
approach. Result Mean age was 67.3 ± 13.8 and mean STS score was 2.7 ±
1.5. Mean aortic cross clamp time for isolated AVR and combined
procedure were 42 ± 11 and 74 ± 23 respectively. There was no
in-hospital mortality. 3 patients required ventilation for
\textgreater{} 24 hours. New onset left bundle branch block occurred in
4 patients which recovered before discharge in 2 patients. The peak and
mean valve gradients were satisfactory. None of implanted valve showed
para-valvular leak. Conclusion SAVR using Perceval Sutureless valve is
associated with excellent results and represent a safe and effective
treatment option for patients with severe AS. This valve also
facilitates MI approach and reduces aortic x-clamp and cardiopulmonary
bypass time.%
\end{abstract}\selectlanguage{ngerman}%



\sloppy


Title Page

\textbf{Title of Manuscript} -Perceval Sutureless Valve-A limbo concept
or a future trial

\textbf{Authors:-}

\textbf{Ajeet Bana(MCh)}Chairman CTVS

Eternal Heart Care Centre,

Jaipur, Rajasthan

\emph{email-bana\_ajeet@yahoo.co.in}

\textbf{Saurabh Jaiswal(MCh)}

Director \& Head of Department CTVS

Eternal Heart Care Centre,

Jaipur, Rajasthan

\emph{email-saurabhjaiswal79@gmail.com}

\textbf{Vimalkant Yadav(MCh)}

Senior Consultant and Incharge of Heart Transplant

Eternal Heart Care Centre,

Jaipur, Rajasthan

\emph{email-vkyadav@live.in}

\textbf{Mukta Tiwari}

Department of CTVS

Eternal Heart Care Centre,

Jaipur, Rajasthan

\emph{email-muktatiwari2@gmail.com}

\textbf{Anuj Sangal(MD)} -Corresponding Author

Associate Consultant CTVS

Eternal Heart Care Centre,

Jaipur, Rajasthan

\emph{email-dranujsangal23@gmail.com}

\textbf{Abstract -}

Objective

Aortic stenosis has traditionally been addressed with surgical aortic
valve replacement with a stented prosthesis. Several technologies have
emerged as an alternative treatment method for aortic valve disease.
Among them, Perceval Sutureless valve has been used in clinical practice
for more than a decade. The aim of this study was to evaluate the
results of Perceval Sutureless valve from single centre in Indian
population.

Method

Between April 2018 to December 2021, 30 elective patients underwent
aortic valve replacement with the Perceval Sutureless valve. 19 patients
had isolated AVR and 11 patients underwent AVR + Coronary artery bypass
grafting (CABG) with average grafts 2.1 \selectlanguage{ngerman}± 0.8. Majority of isolated AVR,
12 of 19, were done by minimally invasive approach.

Result

Mean age was 67.3 ± 13.8 and mean STS score was 2.7 ± 1.5. Mean aortic
cross clamp time for isolated AVR and combined procedure were 42 ± 11
and 74 ± 23 respectively. There was no in-hospital mortality. 3 patients
required ventilation for \textgreater{} 24 hours. New onset left bundle
branch block occurred in 4 patients which recovered before discharge in
2 patients. The peak and mean valve gradients were satisfactory. None of
implanted valve showed para-valvular leak.

Conclusion

SAVR using Perceval Sutureless valve is associated with excellent
results and represent a safe and effective treatment option for patients
with severe AS. This valve also facilitates MI approach and reduces
aortic x-clamp and cardiopulmonary bypass time.

\textbf{Key Words:} Aortic Stenosis, AVR, Minimally Invasive Surgery,
Sutureless Valve

\textbf{Perceval Sutureless Valve-A limbo concept or a future trial}

\textbf{1. Introduction}

SAVR performed by median sternotomy has been the surgical standard of
care for lesions of the aortic valve (1). Elective SAVR is associated
with low morbidity, mortality and results in significant improved
quality of life (2).

According to the society of thoracic surgeon (STS) database, the
operative risk of SAVR has dramatically improved in the last decade,
showing reduction in mortality from 4.3\% to 2.6\% (3).

In the past few years, the incidence of degenerative aortic valve
disease has increased as a consequence of increased life expectancy (4).
These patients of AS are elderly patients with severe co morbidities,
leading to an increase operative risk and inherent higher morbidity and
mortality risks (5).

In recent years, transcatheter aortic valve implantation (TAVI) has
emerged as MI approach to treat these high risk patients. The PARTNER 1
and 2 studies have demonstrated the superiority of TAVI or medical
therapy in patients deemed to be inoperable and non-inferiority of TAVI
in high and intermediate risk patients when compared with SAVR (6, 7).
Presently TAVI has moved to even in the low risk patients. (8) Despite
improvement in design of Transcatheter valves, rate of pacemaker
implantations, vascular complications and PVL are still higher with TAVI
in comparison to SAVR (9).

Another inherent problem of transcatheter valve is crimping, which can
lead to the damage of bio-prosthetic valve (10) and may effect long-term
durability. Also, in Indian scenario, the cost of transcatheter valve is
another important factor, limiting the use of TAVI in larger population
(11).

This changing management for intervention on AV disease towards less
invasive TAVI approach has led to the development of ways of reducing
the physiological impact of SAVR. Sutureless implantation can reduce
x-clamp and CPB time. It also facilitates minimally invasive aortic
valve replacement (MIAVR), whereas the lack of stent and swing ring
enables improved hemodynamics (12, 13). Current clinical experience
demonstrates promising results for Sutureless valve technologies, such
as reduced cardiac ischemia, CPB times and facilitated MI procedures.
(14)

This study reports the largest single center experience of Sutureless
Perceval valve along with its hemodynamic performance and the clinical
outcome during early follow-up in Indian patients.

\textbf{2. Material and Methods}

\textbf{(a) Patients}

Between April 2018 to December 2021, 30 elective patients underwent AVR
with the Perceval Sutureless Valve. Inclusion criteria were critical
aortic valve stenosis, age \textgreater{} 60 years and patient opting
for sutureless valve. The informed consent was in all patients.
Exclusion criteria includes patient not opting for sutureless valve,
ratio between Sino tubular junction to annulus \textgreater{} 1.3,
bicuspid aortic valve, dilated ascending aorta and annulus \textless{}
18mm. Patients demographic profile and pre-operative echocardiography
findings are mentioned in Table 1 and 2.

Out of 30 patients, 19 were isolated AVR and 11 patients underwent
combined AVR + Coronary Artery Bypass Grafting (CABG) with average
number of grafts were 2.1 ± 0.8. (Table 3)

The study was approved by the ethics committee of our hospital. Post
operatively, all patients were prescribed oral anticoagulation drug for
three months to maintain INR up to 2.0, later on it was replaced with
either single or dual antiplatelet drugs depending upon CABG or no CABG.

\textbf{(b) Surgical technique}

Majority of isolated aortic valve replacements (12 of 19) were done by
MI approach either right anterior thoracotomy or upper partial
sternotomy.

Right anterior thoracotomy was used for right-ward aorta and \selectlanguage{greek}α \selectlanguage{english}angle
[?]45, whereas upper partial sternotomy was used for centric aorta. In
both of these approaches, peripheral cannulation was done to establish
CPB.

In combined operations like AVR+CABG, full median sternotomy was done
and CPB was established by aortic and right atrial cannulation.

Aortic valve was approached through transverse aortotomy about 2cm above
the conventional incision near the fat pad on ascending aorta. Diseased
aortic valve was excised in toto and all calcium was removed. In all
patients myocardial protection was achieved by Del Nido Cardiopegia.

\textbf{(C) Device and Implantation Technique}

The Perceval bio-prosthetic sutureless valve has two components. The
tissue valve which is made up of Bovine Pericardium, fixed with
Glutaraldehyde and neutralized with homocystic acid. It is a double
sheet design and has eyelets for guiding suture positioning. This tissue
valve is mounted on self-expanding nickel -- titanium alloy stent with
anatomical strut design, double ring geometry and carbo film coating
(Figure-1).

After the excision of diseased valve, its aortic annulus is meticulous
decalcified. The appropriate size of the prosthesis is established when
the valve sizer end marked with ``'' passes easily through the aortic
annulus into the left ventricle, whereas the one marked with ``''
remains stable. Guiding sutures help to position the device at the exact
level: 4-0 polypropylene suture (17mm needle) is placed 2 to 3 mm below
the annulus, across the annulus, and exiting the aortic wall 2 to 3 mm
above the annular line. This placement ensures that the bite is large
enough to hold the traction applied during implantation of the device
and the Perceval valve is not anchored too low in the left ventricular
outflow tract (LVOT).

After the lower needle of the guiding suture has been passed through the
eyelets of the device, the holder with the loaded valve is guided down
to the annular level. Gentle traction is applied to the guiding sutures
almost parallel to the holder, not tangled around the stent posts, while
commissural stay sutures are released. Deployment is started with the
screw on the tip of the implanting device, which unscrews the inflow
portion of the valve. After that, the safety clip is removed, and the
sheath is pulled back to deploy the outflow part of the stent. After
deployment is complete, the holder is removed gently, avoiding
entangling the device in the prosthesis. Accurate positioning of the
valve is then reconfirmed. Post-ballooning is carried out with the
size-dedicated balloon inserted into the prosthesis with the blue ring
at the level of the upper edge of the leaflets. The balloon was inflated
to 2-4 atm of pressure for the duration of 30 seconds depending upon
valve size and annular calcification. After release the balloon is
removed from the LVOT, as are the guiding and stay sutures.

\textbf{Follow-up}

All patients underwent transthoracic echocardiography at discharge, 6
months and 1 year post operatively. EKG was done on zero post op day and
at discharge. It was repeated at 6 months and on completion of one year.

\textbf{3. Results}

In all 30 patients, the Perceval sutureless valve implantation was done
uneventfully. The intraoperative characteristics and procedure details
are mentioned in Table 3. X-clamp and CPB time for isolated aortic valve
were 42 \selectlanguage{ngerman}± 11 and 54 ± 14 whereas 74 ± 23 and 101 ± 36 in combined
procedures.

Intra operative valve hemodynamics were excellent with mean gradient of
13 ± 2.7 and peak gradient 21 ± 8.4 by post procedure intra operative
TEE. No patient had PVL in immediate post-operative period. Pre
discharge valve hemodynamics were also satisfactory and no patient had
AR or PVL at discharge. 22 patients completed 1 year follow-up and 27
completed 6 months follow-up. All patient's echocardiography showed
excellent valve hemodynamics and improved LV function. (Table 5).

\textbf{Cardiac Rhythm and Pacemaker}

Pre-operatively all patients were in normal sinus rhythm except one
patient who had right bundle branch block (RBBB). In immediate
post-operative period 22 patients came in NSR, 4 patients developed left
bundle branch block (LBBB), in two patients it reverted to narrow QRS in
ICU whereas in two patients LBBB persisted in follow-up. The patient
having RBBB pre-operatively, developed complete heart block in immediate
post-operative period which recovered on
6\textsuperscript{th}post-operative day, but RBBB persisted.

\textbf{Post-operative course and follow-up}

Average ICU stay was 2.4 ± 1.1 and hospital stay was 6.7 ± 1.2 in
isolated AV replacement. In MI SAVR approach, shorter hospital and ICU
stay was observed. Patient requiring combined procedure had longer
hospital and ICU stay 10.9 ± 2.4 \& 3.9 ± 1.6 respectively. Three
patient required ventilation for \textgreater{} 24 hours and all of
these were AVR + CABG patients. New onset atrial fibrillation was
noticed in 4 patients and 3 patients had rising serum creatinine and
they all responded to medical management. (Table 4)

There were no in-hospital mortality. All patients were in good clinical
condition and maintained NYHA class I during entire follow-up period.
There was no event observed related to implanted valve dysfunction.

\textbf{4. Discussion}

Multiple non-randomized studies, meta-analyses and registry have shown
that Sutureless rapid deployment aortic tissue valve is safe and
effective alternate to conventional SAVR and associated with improved
clinical outcomes.

In majority of published studies on Perceval valve, the average age of
patient was \textgreater{} 75 years, where as in our study the average
age was 67.3 ± 13.8 years. Major advantage of Perceval sutureless valve
was observed in intermediate and high risk group (15,16) whereas in our
study all patients were in low or intermediate risk group with average
STS score of 2.71 ± 1.54.

Various studies have demonstrated that duration of aortic x-clamp and
CPB are independent predictors of survival after valve replacement and
combined valve operation with CABG (17). In our study the average
x-clamp time of 42 ± 11 minutes in isolated aortic valve and 74 ± 23
minutes in combined procedures. The CPB time was 54±14 minutes in
isolated AVR and 101±36 in combined procedures. We observed 18\%
reduction in x-clamp time and 22\% reduction in CPB time when we
compared it with standard bio-prosthetic sutured valve by same surgeon.
In CABG + AVR patient all distal anastomosis were done on pump beating
heart which further reduced the x-clamp time.

Recently published Persist AVR trial has shown 30\% reduction in x-clamp
time and 20-25\% reduction in CPB time by using Perceval in comparison
of standard AVR in isolated AVR surgery (18).

In our experience we could perform MIAVR in 12 out of 19 isolated AVR
patients. In SURD-IR registry it was observed that less invasive
approach was used in two third of study patients and in 50\% high risk
patients, with good intermediate results in all risk categories (19).

In our study also we did not find any significant difference in x-clamp
and CPB time between sternotomy AVR and MIAVR with use of Perceval, but
the patient number are less to reach to a real conclusion.

There was no PVL in any of our patients. The vast majority of published
reports shown very low rate of moderate to severe PVL (21) with proper
decalcification, sizing and valve positioning, PVL is comparable with
standard SAVR (14).

The rate of permanent pacemaker implantation has been a bit of concern
with the Perceval. The majority of the literature reports of PPI between
6\% and 9\%. However some studies have reported rate as high as 23\%
(22). In order to avoid PPI, the key points are (i) proper
decalcification of the annulus, (ii) correct sizing and certainly avoid
over sizing, (iii) proper placement of guiding sutures, (iv) Adjusting
balloon inflation between 2to 4mmHg (15), by using these modified
guidelines we have noticed significant improved in rate of PPI.

4 patients developed new onset LBBB in immediate post-operative period.
In two patients, it was recovered to normal EKG in ICU where as in 2
patients it was persisted in follow-up. One patient with preexisting
RBBB had complete heart block in immediate post-operative period
requiring temporary pacing but it was recovered on
6\textsuperscript{th}post-operative day. 2 patients developed new onset
LBBB post implant which was persistent during follow-up. We had 2.4 ±
1.1 and 3.9 ± 1.6 days ICU stay and 6.7 ± 1.2 and 10.9 ± 2.4 days
hospital stay in isolated AVR and combined procedure respectively. In
these small number of patients we did not find much difference in ICU
and hospital stay when compare to standard sutured aortic valve.
Multiple studies have reported decrease in ICU stay and blood
transfusions with use of Perceval sutureless valve in isolated AVR (23).
Marco Solinas et al reported reduction of ICU and hospital stay by
adding Perceval valve and right anterior thoracotomy(20). In an
international prospective registry statistically significant difference
was noticed in ICU and hospital stay by using sutureless valve and MIAVR
approach (24).

Rate of intraoperative stroke range from 0 to 5\% for the Perceval and
2.5 to 5\% for TAVI (26, 27). Data from Partner II trial and German
registry indicates that the incidence of PVL after TAVI is significantly
higher when compared with Sutureless aortic valve (28). SURD-IR registry
has shown that in low risk patients, the mortality rate was lower in
sutureless valve then that recorded in the NOTION trial 1.55 vs 2.1\%
(29). The most important piece of data concerns to patients deemed at
very high risk, a patient population comparable to that included in the
PARTNER trial cohort B (6). In this trial in hospital mortality was 2
fold higher than that observed in SURD-IR registry for sutureless valve
(2.6\% vs 5\%) (19).

In two female patients with small aortic annulus, small size Perceval
valve was implanted. Both patient showed excellent valve hemodynamics in
post-operative period with no patient prosthesis mismatch.

In our limited experience, morbidity was low and we did not have any
mortality even in follow-up. SURD-IR registry has compared the morbidity
and mortality in patients undergoing sutureless rapid deployment valve
and they found a extremely satisfactory results even in high risk (EURO
score \textgreater{} 10 - 20\%) and very high risk (EURO score
\textgreater{} 20\%) patients (19).

We noticed stable hemodynamics and satisfactory gradient in all our
patients at 6 months and 1 year follow-up and none of our patient
developed central or PVL.

The health economics of Perceval sutureless valve is highly dependent on
the healthcare system, however the ability to facilitate MI surgery will
enhance its cost effectiveness by reducing ICU stay, hospital stay and
blood usage. Especially in high risk patients using sutureless valve
instead of TAVI will further reduce the prosthesis cost (11).

\textbf{5. Conclusion}

AS is a highly prevalent disease and its incidence is expected to
increase further, due to ageing population in India. The development of
MI approach has allowed surgeons to treat patients with multiple
co-morbidities. Perceval sutureless valve also enhances the feasibility
of MIAVR by quick and reproducible valve implantation along with
decalcification of the aortic annulus. In our limited experience, the
Perceval sutureless valve is most useful in MIAVR, combined procedure
and in high risk patient's sensitive to x-clamp and CPB time. Rate of
Permanent Pacemaker implantation has been reduced significantly by
technical changes and it will further reduces with introduction of new
design Perceval sutureless valve. This valve also proves to be good
alternate to TAVI in cost reduction. Satisfactory mid-term and long-term
durability has been shown in various studies (18).

With increase in the number of Perceval sutureless valve implantation in
India, the experience of other surgeons and center will also contribute
to our findings and feasibility of its wide use.\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Number of Patients Male Female & 30 19 11\tabularnewline
Age (Mean \selectlanguage{ngerman}± SD) & 67.3 \selectlanguage{ngerman}± 13.8\tabularnewline
STS Score (Mean ± SD) & 2.70 \selectlanguage{ngerman}± 1.54\tabularnewline
NYHA class II III & 07 23\tabularnewline
Risk Factors HT DM COPD Previous MI Unstable Angina & 19 12 06 09
03\tabularnewline
Pre-Operative EKG NSR RBBB & 29 01\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table -1} Patient Demographics\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
Severe AS & 27\tabularnewline
AS + AR & 03\tabularnewline
Peak Gradient & 74 \selectlanguage{ngerman}± 12\tabularnewline
Mean Gradient & 44.5 \selectlanguage{ngerman}± 19.2\tabularnewline
Valve Orifice Area & 0.51 \selectlanguage{ngerman}± 0.16\tabularnewline
LVEF (\%) \textgreater{} 50 35-50 \textless{} 35 & 07 20
03\tabularnewline
Valve Annulus Diameter \textless{} 19 mm 19 -- 21 22 -- 23 24 -- 25 26
-- 27 & 02 05 12 07 04\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table -2} Preoperative 2D Echocardiography\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Isolated AVR MIAVR Upper Sternotomy Right anterior thoracotomy Mid
sternotomy AVR\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
19 05 07 07\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
Combined Procedure CABG (Average Graft)\strut
\end{minipage} & \begin{minipage}[t]{0.48\columnwidth}\raggedright\strut
11 ( 2.1 \selectlanguage{ngerman}± 0.8)\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
X- clamp Time Isolated AVR Combined\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
48 \selectlanguage{ngerman}± 11 81 ± 23\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
CPB Time Isolated AVR Combined\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
63 \selectlanguage{ngerman}± 14 106 ± 36\strut
\end{minipage}\tabularnewline
\begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
Perceval Valve Size S M L XL\strut
\end{minipage} & \begin{minipage}[t]{0.47\columnwidth}\raggedright\strut
07 13 06 04\strut
\end{minipage}\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table - 3} Intra operative characteristics\selectlanguage{english}
\begin{longtable}[]{@{}ll@{}}
\toprule
1. Ventilation \textgreater{} 24 Hours & 3\tabularnewline
2. New onset AF & 4\tabularnewline
3. Rising serum creatinine \textgreater{} 2mg/dl & 3\tabularnewline
4. Post-operative EKG NSR New onset LBBB CHB & 25 04 01\tabularnewline
5. ICU stay (Days) Isolated AVR Combined Procedure & 2.4 \selectlanguage{ngerman}± 1.1 3.9 ±
1.6\tabularnewline
6. Hospital stay (Days) Isolated AVR Combined Procedure & 6.7 \selectlanguage{ngerman}± 1.2 10.9
± 2.4\tabularnewline
7. In Hospital Mortality & Nil\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table -- 4} Post-operative course\selectlanguage{english}
\begin{longtable}[]{@{}llll@{}}
\toprule
& At Discharge (n = 30) & At 6 months (n = 27) & After 1 year (n =
22)\tabularnewline
Peak Gradient & 22 \selectlanguage{ngerman}± 9.7 & 18 \selectlanguage{ngerman}± 4.8 & 19 \selectlanguage{ngerman}± 5.6\tabularnewline
Mean Gradient & 11 \selectlanguage{ngerman}± 2.9 & 10 \selectlanguage{ngerman}± 2.6 & 11 \selectlanguage{ngerman}± 1.8\tabularnewline
EOA & 1.5 \selectlanguage{ngerman}± 0.7 & 1.6 \selectlanguage{ngerman}± 0.4 & 1.5 \selectlanguage{ngerman}± 0.9\tabularnewline
PVL & Nil & Nil & Nil\tabularnewline
AR & Nil & Nil & Nil\tabularnewline
EF (\%) \textgreater{} 50 35 -- 50 \textless{} 35 & 07 21 02 & 08 17 02
& 09 13 00\tabularnewline
\bottomrule
\end{longtable}

\textbf{Table -- 5} Post-operative and follow-up Echocardiography\selectlanguage{english}
\begin{figure}[H]
\begin{center}
\includegraphics[width=0.70\columnwidth]{figures/image1/image1}

\end{center}
\end{figure}

\textbf{Figure - 1-Perceval Sutureless Aortic Valve Prosthesis}



\textbf{References:}

1. Rosu, C., Soltesz, E.G.~Selection of valve prostheses. Semin Thorac
Cardiovasc Surg.~2015; 27:~152--158.

2. Carabello, B.A.~Is it ever too late to operate on the patient with
valvular heart disease?~J Am Coll Cardiol.~2004; 44:~376--383.

3. Shrestha M, Folliguet T, Meuris B, et al.~Sutureless Perceval S
aortic valve replacement: A multicenter, prospective pilot trial.~J
Heart Valve Dis~2009; 18:698-702.

4. C.N. Manjunath,~P. Srinivas, K.S. Ravindranath et al. Incidence and
patterns of valvular heart disease in~a tertiary care high-volume
cardiac center: A~single center experience, Indian Heart J.~2014 May;
66(3): 320--326.

5. Mohr FW., Holzhey D., M\selectlanguage{ngerman}öllmann H~et al.~The German Aortic Valve
Registry: 1-year results from 13,680 patients with aortic valve disease.
Eur J Cardiothorac Surg~2014; 46:~808--816.

6. Leon MB, Smith CR, Mack M, et al.~Transcatheter Aortic-Valve
Implantation for Aortic Stenosis in Patients Who Cannot Undergo
Surgery.~N Engl J Med~2010; 363:1597-607.

7. Leon MB, Smith CR, Mack MJ, et al.~Transcatheter or Surgical
Aortic-Valve Replacement in Intermediate-Risk Patients.~N Engl J
Med~2016; 374:1609-20.

8. Gilbert H.L. Tang, Subodh Verma, Deepak L. Bhatt Transcatheter Aortic
Valve Replacement in Low-Risk patients -- A New Era in the Treatment of
Aortic Stenosis, Circulation. 2019; 140: 801-803.

9. Kunal V. Patel,~Wally Omar,~Pedro Engel Gonzalez et al, Expansion of
TAVR into Low-Risk Patients and Who Consider for SAVR, Cardiol Ther
2020; 9: 377 -- 394.

10.S. Hamed Alavi, Elliott M. Groves, Arash Kheradvar, The Effects of
Transcatheter Valve Crimping on Pericardial Leaflets Ann Thorac Surg
2014;97:1260--6.

11. Bana A; TAVR---present, future, and challenges in developing
countries Indian Journal of Thoracic and Cardiovascular
Surgery~volume~2019; 35,~473--484.

12. Pollari, F., Santarpino, G., Dell'Aquila, A.M.~Better short-term
outcome by using sutureless valves: a propensity-matched score analysis.
Ann Thorac Surg.~2014; 98:~611--616.

13. Santarpino, G., Pfeiffer, S., Concistré, G. et al. The Perceval S
aortic valve has the potential of shortening surgical time: does it also
result in improved outcome?~Ann Thorac Surg.~2013; 96:~77--81.

14. Meco M., Montisci A., Miceli A. et al. Sutureless Perceval aortic
valve versus conventional stented bioprostheses: meta-analysis of
postoperative and midterm results in isolated aortic valve replacement.
J~Am Heart Assoc.~2018;~7:~1-9.

15. Ferdinand Vogt,~Marco Moscarelli,~Anna Nicoletti et al. Sutureless
aortic valve and pacemaker rate : from surgical tricks to clinical
outcomes Ann Thorac Surg.~2019 Jul;108 (1) :99-105.

16. Delphine Szecel,~Roxanne Eurlings,~Filip Rega et al. Perceval
sutureless aortic valve implantation: mid-term outcomes. Ann Thorac
Surg.~2021 Apr;111(4):1331-1337.

17. Ranucci M, Frigiola A, Menicanti L, Castelvecchio A et al. Aortic
cross-clamp time, new prostheses, and outcome in aortic valve
replacement. J. Heart Valve Dis 2012;21:732--9.

18.Theodor Fischlein,~Thierry Folliguet,~Bart
Meuris\textsuperscript{~}et al. Sutureless versus conventional
bioprostheses for aortic valve replacement in severe symptomatic aortic
valve stenosis. J Thorac Cardiovasc Surg.~2021 Mar; 161(3):920-932.

19. Giuseppe Santarpino,~Paolo Berretta,~Theodor Fischlein et al.
Operative outcome of patient at low, intermediate, high and `very high'
surgical risk undergoing isolated aortic valve replacement with
sutureless and rapid deployment prostheses: results of the SURD-IR
registry. Eur J Cardiothorac Surg~2019 Jul 1;56(1):38-43.

20. Marco Solinas,~Giacomo Bianchi,~Francesca
Chiaramonti\textsuperscript{~} et al, Right anterior mini-thoracotomy
and sutureless valves: the perfect marriage. Ann Cardiothorac Surg.~2020
Jul;9 (4):305-313.

21. Miceli A, Santarpino G, Pfeiffer S et al.~Minimally invasive aortic
valve replacement with Perceval S sutureless valve: Early outcomes and
one-year survival from two European centers.~J Thorac Cardiovasc
Surg~2014;148: 2838-43.

22. Bouhout I, Mazine A, Rivard L et al.~Conduction Disorders After
Sutureless Aortic Valve Replacement.~Ann Thorac Surg~2017;103:1254-60.

23. Dalén M, Biancari F, Rubino AS et al.~Aortic valve replacement
through full sternotomy with a stented bioprosthesis versus minimally
invasive sternotomy with a sutureless bioprosthesis.~Eur J Cardiothorac
Surg~2016;49:220-7.

24. Paolo Berretta,~Martin Andreas,~Thierry P Carrel et al. Minimally
invasive aortic valve replacement with sutureless and rapid deployment
valve: a report from an international registry (Sutureless and Rapid
Deployment International Registry). Eur J Cardiothorac Surg~2019 Oct
1;56(4):793-799.

25. Siontis GC, Praz F, Pilgrim T et al.~Transcatheter aortic valve
implantation vs. surgical aortic valve replacement for treatment of
severe aortic stenosis: a meta-analysis of randomized trials.~Eur Heart
J~2016;37:3503-12. 10.1093.

26. D'Onofrio A, Salizzoni S, Rubino AS et al.~The rise of new
technologies for aortic valve stenosis: A comparison of sutureless and
transcatheter aortic valve implantation.~J Thorac Cardiovasc
Surg~2016;152:99-109.

27. Santarpino G, Pfeiffer S, Jessl J et al.~Sutureless replacement
versus transcatheter valve implantation in aortic valve stenosis: A
propensity-matched analysis of 2 strategies in high-risk patients.~J
Thorac Cardiovasc Surg~2014;147:561-7.

28. Mattia Glauber,~MD,~Lorenzo Di Bacco,~MD,~Jose Cuenca,~MD~et al.
Minimally Invasive Aortic Valve Replacement with Sutureless Valve :
Results From an International Registry. Innovations Volume: 15 issue:
2,~page(s): 120-130.

29. Thyregod HG, Steinbru¨chel DA, Ihlemann N et al. Transcatheter
versus surgical aortic valve replacement in patients with severe aortic
valve stenosis: 1-year results from the allcomers NOTION randomized
clinical trial. J Am Coll Cardiol 2015;65: 2184--94.

\selectlanguage{english}
\FloatBarrier
\end{document}

