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Objectives: After a panel process, recommendations on the use of sutureless and rapid deployment valves in aortic valve replacement were given with special respect as an alternative to stented valves., Methods: Thirty-one international experts in both sutureless, rapid deployment valves and stented bioprostheses constituted the panel. After a thorough literature review, evidence-based recommendations were rated in a three-step modified Delphi approach by the experts., Results: Literature research could identify 67 clinical trials, 4 guidelines and 10 systematic reviews for detailed text analysis to obtain a total of 28 recommendations. After rating by the experts, 12 recommendations were identified and degree of consensus for each was determined. Proctoring and education are necessary for the introduction of sutureless valves on an institutional basis as well as for the individual training of surgeons. Sutureless and rapid deployment should be considered as the valve prosthesis of first choice for isolated procedures in patients with comorbidities, old age, delicate aortic wall conditions such as calcified root, porcelain aorta or prior implantation of aortic homograft and stentless valves as well as for concomitant procedures and small aortic roots to reduce cross-clamp time. Intraoperative transoesophageal echocardiography is highly recommended, and in case of right anterior thoracotomy, preoperative computer tomography is strongly recommended. Suitable annular sizes are 19-27 mm. There is a contraindication for bicuspid valves only for Type 0 and for annular abscess or destruction due to infective endocarditis. Careful but complete decalcification of the aortic root is recommended to avoid paravalvular leakage; extensive decalcification should be avoided not to create annular defects. Proximal anastomoses of concomitant coronary artery bypass grafting should be placed during a single aortic cross-clamp period or alternatively with careful side clamping. Available evidence suggests that the use of sutureless and rapid deployment valve is associated with (can translate into) reduced early complications such as prolonged ventilation, blood transfusion, atrial fibrillation, pleural effusions and renal replacement therapy, respectively, and may result in reduced intensive care unit and hospital stay in comparison with traditional valves., Conclusion: The international experts recommend various benefits of sutureless and rapid deployment technology, which may represent a helpful tool in aortic valve replacement for patients requiring a biological valve. However, further evidence will be needed to reaffirm the benefit of sutureless and rapid deployment valves., (© The Author 2015. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)

Background and Aim of the Study: The study aim was to monitor serum troponin and plasma lactate concentrations in conventional aortic valve replacement compared to a beating-heart technique, perfused via the coronary sinus., Methods: In this prospective, non-randomized study, which was conducted between 2003 and 2009, a total of 35 patients was allocated to two groups, based on the method of myocardial protection. The groups did not differ significantly in terms of preoperative parameters. Levels of lactate were measured in all 35 patients, and of troponin I in 20 patients, in consecutive samples during and after surgery., Results: There was no in-hospital mortality and no serious complications among patients. The cardiopulmonary bypass and aortic cross-clamp times were each significantly shorter and lactate and troponin I concentrations higher, in the beating-heart group. No perioperative myocardial infarction was observed., Conclusion: Although good clinical results were observed in patients operated when using the beating-heart technique with retrograde coronary sinus perfusion, postoperative serum levels of troponin I were higher than in patients operated on using a conventional technique. Although troponin I is considered a prognostic factor for postoperative mortality, this parameter applies only to selected patients rather than for widespread use.

The protection of ventricular myocardium in aortic valve operations is always an issue because those hearts do not tolerate global ischemia well. A technique of aortic valve replacement is described involving continuous retrograde coronary sinus perfusion with warm oxygenated blood used in 34 patients to date without any complications. This technique maintains a beating heart throughout the procedure.

Objective: The concept of cardiac surgery on the beating heart is acceptable rationale for the cardiac surgery in the next millenium. Beating heart (off-pump) coronary artery bypass grafting (CABG) techniques have led us to consider the possibility for performing the aortic and mitral valve surgery (mitral valve repairs and replacements - with or without CABG) on the beating heart with the technique of retrograde oxygenated coronary sinus perfusion., Methods: We used the technique of retrograde oxygenated blood coronary sinus perfusion in 78 patients (Group All) - (36 patients were with extremely low ejection fraction (Group X) - 62% of whom were in New York Heart Association (NYHA) class 4 and 34% of whom were in NYHA class 3). The procedures for the patients were: aortic, mitral and tricuspid valve surgery, in combination with CABG in ischemic patients. CABG was done in all the cases off-pump. In addition, we performed a case match study for 37 patients with good ejection fraction (51.65 +/- 11.88) (Beating Heart Group) operated on the beating heart with most appropriate group of patients (No. 37) operated in our institutions on arrested heart (ejection fraction 51.07 +/- 12.93) (Arrested Heart Group). The case match selection criteria were: gender, left ventricular ejection fraction, atrial fibrillation, hypertension, pulmonary hypertension, and diabetes. The selected beating heart group and selected arrested heart groups were without statistically significant differences for the mentioned criteria., Results: There were statistically significant differences between Beating Heart Group and Arrested Heart Group in the duration of Cardiopulmonary Bypass Time (69.35 +/- 13.52 min. versus 93.59 +/- 28.54 min.), p<0.001, and statistically significant differences in Aortic Cross Clamp Time (46.5 +/- 8.95 min. versus 61.5 +/- 18.34 min.), p<0.001. The values for Creatinin Kinase (CK) and LDH were not statistically different, however the absolute values for Beating Heart Group were lower. There was no statistical difference in complication rate for both the groups for: sternal infection, bleeding, death, atrial fibrillation, AV block and neurological complications. The total early mortality for all the patients was 5.1% (4 out of 78) - for the group X 8.3 % (3 of 36 patients). Two were in-hospital deaths. One patient with triple-vessel disease and acute mitral insufficiency on intra aortic balloon pump (IABP) had been operated on 6 days after acute myocardial infarction (AMI). The cause of the death was systemic meticillin resistant staphylococus aureus (MRSA) infection - (eight days prior to our operation, arthrodesis of the talocrural joint was performed by an orthopedic surgeon). The other death was a female patient who was operated on after previous multiple cerebrovascular infarctions (CVI) (cause of the death was CVI). In addition, one patient died one month after the operation because of prosthetic valve endocarditis (PVE) on aortic and mitral valves (silver-coated silzone aortic and mitral valves were implanted because of chronic latent asymptomatic tibial osteitis). None of these deaths were cardiac related., Conclusions: We conclude that beating heart valve surgery (any combination) with or without CABG significantly lower the cardiopulmonary bypass and aortic cross clamp time. In addition, the advantages of beating-heart surgery are 1) the perfused myocardial muscle, 2) the heart is not doing any work, 3) no reperfusion injury, 4) the possibility for ablation of atrial fibrillation on the beating heart, and 5) testing of the mitral valve repair is done in real physiologic conditions in the state of left ventricle beating tonus. The procedure could be the procedure of choice for the valve operation or combined operations (valve operation and CABG) in high-risk patients with low ejection fractions. There is no doubt that at present day in cardiac surgery exist at least two major factors for mortality and morbidity after cardiac surgery, which are operation - related, namely cardiopulmonary bypass time and its duration and aortic cross clamp time (ischemic time of myocardium). In the last few years a number of different techniques emerged in the field of cardiac surgery, which were directed toward better results in the selected high risk patients or to minimize the deleterious effects of cardiopulmonary bypass (CPB) on the overall postoperative performance [Calafiore 1996, Tasdemir 1998]. Due to the fact, that the cardiac muscle should be protected at most during the cardiac arrest, retrograde blood cardioplegia was successfully introduced [Buckberg 1990], and more - the warm cardioplegia is being used recently [Kawasuji 1997]. The natural status of the human heart is the beating status, so it is reasonable to try to perform the operations on the beating heart. This has been done recently with the MID - CAB and OP - CAB (off-pump CABG) operations [Tasdemir 1998]. The retrograde warm blood cardioplegia has therefore led us to the premise, that with retrograde oxygenated blood perfusion it would be possible to achieve the operations on the beating heart even in the open heart surgery, such as aortic and/or mitral valve surgery. All will agree that the most damaging effect of the cardioplegia is the reperfusion injury [Allen 1997], and it is obvious that with the technique of retrograde continuous oxygenated blood perfusion this effect will be canceled. In this article, we would like to show the how-to technique for the operations on the beating heart in the case of operations on the aortic valve replacement (AVR) with mitral valve repair (MVR) or replacement MVR and with/without concomitant coronary artery bypass (CABG) surgery. The tricuspid valve repair (PTV) is normally done on the beating heart and there it is realized what problems or technical difficulties may arise during procedures on the mitral valve: the walls of the ventricles are not flattened and the exposure of the mitral valve is challenging task. Furthermore, the free walls of the ventricles with interventricular septum are in the state of the tonus, so every force applied to better expose the aortic or mitral valve is not acceptable