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Dr Bouchard discloses a financial relationship with Perceval.We thank Dr Vogt and colleagues [1Vogt F. Dell’Aquila A.M. Santarpino G. How to prevent pacemaker implantation after sutureless aortic valve replacement: tips and tricks.Ann Thorac Surg. 2017; 104 (letter): 720-721Abstract Full Text Full Text PDF PubMed Scopus (7) Google Scholar] for their comments on our article [2Bouhout I. Mazine A. Rivard L. et al.Conduction disorders after sutureless aortic valve replacement.Ann Thorac Surg. 2017; 103: 1254-1261Abstract Full Text Full Text PDF PubMed Scopus (42) Google Scholar] and for their pioneering work in refining the surgical technique for sutureless aortic valve replacement. Dr Bouchard discloses a financial relationship with Perceval. There is wide variability in the reported incidence of postoperative pacemaker implantation rates following sutureless aortic valve replacement with the Perceval S prosthesis (LivaNova, London, UK). This variability may be related to several factors, including different patient risk profiles, influence of the “learning curve”, and institutional approach towards management of postoperative conduction disorders—namely, aggressive pacemaker implantation versus conservative “watchful waiting”. Although the self-expanding nature of the Perceval S device poses an inevitable a risk of aortic wall compression and conduction tissue impingement, recent evidence suggests that technical factors may play a determining role in mitigating this risk. Yanagawa and colleagues recently introduced a technical modification by which the three guiding sutures of the Perceval S are placed at the nadir of each cusp, instead of a few millimeters below, as recommended by the manufacturer [3Yanagawa B. Cruz J. Boisvert L. Bonneau D. A simple modification to lower incidence of heart block with sutureless valve implantation.J Thorac Cardiovasc Surg. 2016; 152: 630-632Abstract Full Text Full Text PDF PubMed Scopus (44) Google Scholar]. This minute refinement led to a dramatic decrease in the incidence of postoperative pacemaker implantation. The Nuremberg group has also made significant contributions in this arena [4Fischlein T. Gersak B. Pfeiffer S. How to prevent a pacemaker implantation after sutureless bioprosthesis.J Thorac Cardiovasc Surg. 2016; 152: 635-636Abstract Full Text Full Text PDF PubMed Scopus (24) Google Scholar]. In addition to the use of semicircular needles to facilitate the appropriate depth of suture placement in relation to the annulus, the authors highlight the importance of maintaining coaxiality of the prosthesis with the aortic annulus during deployment. In our experience, thorough decalcification of the aortic annulus, as well as adequate sizing, are two additional key factors in minimizing the risk of postoperative conduction disorders. Both undersizing and oversizing should be avoided, as the former may lead to prosthesis migration or central leak, and the latter may lead to stent invagination, as well as excessive compression near the bundle of His. In a previously published multicenter study, we have reported an association between sutureless prosthesis size and rates of permanent pacemaker implantation, supporting the notion that oversizing may be an incriminating factor [5Mazine A. Teoh K. Bouhout I. et al.Sutureless aortic valve replacement: a Canadian multicentre study.Can J Cardiol. 2015; 31: 63-68Abstract Full Text Full Text PDF PubMed Scopus (67) Google Scholar]. Finally, our group examined the impact of postdeployment balloon inflation of the Perceval S prosthesis on the incidence of postoperative conduction disorders, and found no difference between patients who underwent balloon dilatation and those who did not. How to Prevent Pacemaker Implantation After Sutureless Aortic Valve Replacement: Tips and TricksThe Annals of Thoracic SurgeryVol. 104Issue 2PreviewThe use of the sutureless aortic valves combined with the surgeon’s learning curve has posed unprecedented challenges requiring refinements in the implantation technique by the pioneers in this field [1]. Full-Text PDF