In-Hospital Outcome in Women with Small Aortic Annuli Undergoing Isolated Aortic Valve Replacement: A Comparative Analysis of Stented vs. Sutureless Valves

All articles of this category (opens in new window) Background: Surgical aortic valve replacement (SAVR) in small annuli (≤21 mm) remains challenging, especially in women. Conventional sutured valves may lead to patient–prosthesis mismatch (PPM) due to limited inner diameter and orifice area. Sutureless prostheses were developed to overcome these limitations by offering larger functional valve areas and shorter procedure times. This study compared hemodynamic performance, perioperative outcomes, and PPM incidence between Perceval sutureless valves size S/M (PER) and conventional sutured 21 mm bioprostheses (CON) in women with small annuli undergoing AVR. Methods: Between 2011 and 2023, 94 women with small aortic annuli (≤21 mm) underwent isolated SAVR: 40 of these received PER and 54 received CON. The incidence of PPM, procedural variables, hemodynamics, early outcomes, and 30-day mortality were retrospectively assessed according to VARC-3 criteria. Results: Baseline characteristics were comparable between CON vs. PER (age 70.5 ± 8.9 vs. 70.7 ± 7.1 years; p = 0.935; EuroSCORE II 2.0 ± 1.2% vs. 1.7 ± 1.4%; p = 0.331; STS PROM 2.4 ± 1.5% vs. 2.1 ± 1.0%; p = 0.357). Cardiopulmonary bypass times were similar, whereas aortic cross-clamp times were significantly shorter in the PER group (60.0 ± 18.1 vs. 50.4 ± 11.4 minutes, CON vs. PER; p = 0.004). There were no significant differences between CON vs. PER in rates of myocardial infarction (3.7% vs. 0.0%; p = 0.218), stroke (1.8% vs. 2.5%; p = 0.829), rethoracotomy due to bleeding (1.8% vs. 12.5%; p = 0.081), acute kidney injury (AKIN 2.3; 3.7% vs. 7.5%; p = 0.417), and pacemaker implantation (3.7% vs. 5.0%; p = 0.758). Thirty-day mortality was low and comparable between CON vs. PER (1.8% vs. 0%; p = 0.386), with only death attributed to multiorgan failure. Echocardiographic assessment revealed comparable mean transvalvular gradients (13.7 ± 5.4 vs. 12.2 ± 3.9 mmHg; p = 0.134). Incidence of moderate PPM was significantly lower in the PER group (68.5% vs. 30.0%; p = 0.002), while severe PPM was rare and not present in the PER group (5.6% vs. 0%, CON vs. PER; p = 0.129). Conclusion: Our findings show that in women with aortic annuli ≤ 21 mm, both Perceval sutureless and conventional bioprostheses are technically feasible and safe. The sutureless valve was associated with shorter cross-clamp times, no rise in pacemaker implantation, and a significantly lower rate of moderate PPM. These results support sutureless bioprostheses as a valuable option for women with small annuli. Publication History Article published online: 17 February 2026 © 2026. Thieme. All rights reserved. Georg Thieme Verlag KG Oswald-Hesse-Straße 50, 70469 Stuttgart, Germany