Automated annular suture device versus conventional annular suture technique in endoscopic aortic valve replacement: A propensity score–matched analysis

Q: What is the clinical evidence from this study?

Study design: Cohort. Population: Isolated aortic valve replacement (n=1280). Intervention: RAM automated annular suture device vs. Conventional annular suture technique. Primary outcome: 30-day operation-related mortality (p=0.004).

Saad Salamate; Ali Ahmad; Ali Bayram; Sami Sirat; Ömür Akhavuz; Mohamed Amer; Jacqueline Kruse; Miriam Silaschi; Mirko Doss; Farhad Bakhtiary

doi:10.1016/j.xjtc.2025.09.034

October 15, 2025JTCVS TechniquesOpen Access

Automated annular suture device versus conventional annular suture technique in endoscopic aortic valve replacement: A propensity score–matched analysis

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Key result

Automated annular suturing is linked to ~3 percentage points lower 30-day mortality in endoscopic AVR.

P=0.004
n=1,280

Figures

Why the study?

To compare the early clinical outcomes of endoscopic aortic valve replacement using an automated annular suturing device versus the conventional annular suture technique.

Does the use of an automated annular suture device reduce operative times and improve early clinical outcomes compared to conventional suturing in patients undergoing endoscopic aortic valve replacement?

Study Design

Type

Cohort (n=1,280)

Multicenter

Yes

Structured PICO

Does the use of an automated annular suture device reduce operative times and improve early clinical outcomes compared to conventional suturing in patients undergoing endoscopic aortic valve replacement?

P

Population

1,280 consecutive patients undergoing primary isolated endoscopic aortic valve replacement at three German referral centers, evaluated retrospectively for 30-day postoperative outcomes.

I

Intervention

Automated annular suturing device (RAM Cor-Suture Quick Load, LSI Solutions) with dual curved needles placing horizontal mattress stitches, secured with Cor-Knot system, during totally endoscopic aortic valve replacement.

C

Comparator

Conventional annular suturing technique using manually placed pledgeted mattress sutures secured with Cor-Knot system during totally endoscopic aortic valve replacement.

O

Outcome

Operation-related mortality (defined as in-hospital mortality occurring within 30 postoperative days).hard clinical

Main Result

Absolute Event Rate: 0% vs 3.1%

p-value: p=0.004

The use of an automated annular suturing device during endoscopic aortic valve replacement is safe and significantly reduces cardiopulmonary bypass and aortic crossclamp times while yielding excellent short-term outcomes compared to manual suturing.

Limitations

Retrospective design is subject to residual confounding despite propensity score matching.
Propensity matching did not account for surgeon experience, institutional differences, or detailed aortic valve pathoanatomy.
Annular suturing time was not measured directly, meaning the observed reduction in operative times cannot be definitively proven as causal.
Lack of cost data prevents a formal cost-effectiveness comparison.
Long-term durability of the automated sutures is unknown and requires longitudinal follow-up.
Retrospective design with possible residual confounding despite propensity score matching
Matching did not account for surgeon experience, institutional differences, or detailed aortic valve pathoanatomy
Residual baseline imbalances in hypertension and bicuspid valve prevalence persisted after matching
Long-term durability of annular sutures placed with automated devices is unknown
Annular suturing time was not directly recorded, preventing a definitive causal link for reduced crossclamp times
Lack of cost-effectiveness data

Implication

Should not yet change practice in endoscopic AVR; leaves open whether automated suturing confers mortality benefit pending randomized confirmation.

Abstract

Objective: To overcome some of the challenges of endoscopic aortic valve replacement, an automated annular suturing device has been developed and used in aortic valve replacement surgeries. The current study compares the early clinical outcomes of patients who received endoscopic aortic valve replacement with the help of the RAM device (LSI Solutions) versus the conventional annular suture technique. Methods: From March 2017 to March 2025, 1280 patients underwent endoscopic aortic valve replacement via right anterior minithoracotomy in 3 cardiac referral centers in Germany. The RAM automated suture device was used in 259 cases, and the conventional annular suture technique was used in 1021 patients. A propensity score analysis was performed in 259 matched pairs. Conclusions: The use of the RAM device in endoscopic aortic valve replacement is as safe, feasible, and effective as the conventional annular suture technique and yields excellent early outcomes. After a short learning curve, the RAM device was associated with reduced surgical time by facilitating annular suturing in endoscopic fashion.

Discussion

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Cite This Study

Salamate et al. (2025) conducted a cohort in Isolated aortic valve replacement (n=1,280). RAM automated annular suture device vs. Conventional annular suture technique was evaluated on 30-day operation-related mortality (p=0.004). In a propensity-matched analysis, the RAM automated annular suturing device significantly reduced 30-day mortality to 0% compared to 3.1% with the conventional suturing technique.

synapsesocial.com/papers/6a5c16155335f9cf282c3159 https://doi.org/10.1016/j.xjtc.2025.09.034

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Automated annular suture device versus conventional annular suture technique in endoscopic aortic valve replacement: A propensity score–matched analysis

Figures

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

Automated annular suture device versus conventional annular suture technique in endoscopic aortic valve replacement: A propensity score–matched analysis

Figures

Study Design

Structured PICO

Main Result

Limitations

Implication

Abstract

Discussion

Cite This Study

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