Hemodynamic Follow-Up after Valve-in-Valve TAVR for Failed Aortic Bioprosthesis

Abstract

Background VIV-TAVR is established and provides good initial clinical and hemodynamic outcomes. Lacking long-term durability data baffle the expand to lower risk patients. For those purposes, the present study adds a hemodynamic 3-years follow-up. Methods A total of 77 patients underwent VIV-TAVR for failing aortic bioprosthesis during a 7-years period. Predominant mode of failure was stenosis in 87.0%. Patients had a mean age of 79.4±5.8 years and a mean logistic EuroSCORE of 30.8±15.7%. The STS-PROM averaged 5.79±2.63%. Clinical results and hemodynamic outcomes are reported for 30-days, 1-, 2- and 3-years. Completeness of follow-up was 100% with 44 patients at risk after 3-years. Follow-up ranged up to 7.1 years. Results Majority of the surgical valves were stented (94.8%) with a mean labeled size of 23.1±2.3mm and true-ID of 20.4±2.6mm. A true-ID ≤21mm had 58.4% of the patients. Self-expanding valves were implanted in 68.8% (mean labeled size 24.1±1.8mm) and balloon-expanded in 31.2% (mean size 24.1±1.8mm). No patient died intraoperatively. Hospital mortality was 1.3% and three-years survival 57.1%. All patients experienced an initial significant dPmean-reduction to 16.8±7.1mmHg. After 3-years mean dPmean raised to 26.0±12.2mmHg. This observation was independent from true-ID or type of TAVR-prosthesis. Patients with a true-ID ≤21mm had a higher initial (18.3±5.3mmHg vs. 14.9±7.1mmHg; p=0.005) and dPmean after 1-year (29.2±8.2mmHg vs. 13.0±6.7mmHg; p=0.004). There were no significant differences in survival. Conclusions VIV-TAVR is safe and effective in the early period. In surgical valves with a true-ID≤21mm inferior hemodynamic and survival outcomes must be expected. Nonetheless, also patients with larger true-ID’s showed steadily increasing transvalvular gradients. This raises concern about durability.