Hemodynamic outcomes after valve-in-valve transcatheter aortic valve replacement: a single-center experience

Abstract

Background: Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has emerged as a safe, effective alternative to redo aortic valve surgery in high-risk patients with degenerated surgical bioprosthetic valves. However, ViV-TAVR has been associated high postprocedural valvular gradients, compared with TAVR for native-valve aortic stenosis.Methods: We performed a retrospective study of all patients who underwent ViV-TAVR for a degenerated aortic valve bioprosthesis between January 1, 2013 and March 31, 2019 at our center. The primary outcome was postprocedural mean aortic valve gradient. Outcomes were compared across surgical valve type (stented versus stentless), surgical valve internal diameter (≤19 versus >19 mm), and transcatheter aortic valve type (self-expanding vs. balloon-expandable).Results: Overall, 89 patients underwent ViV-TAVR. Mean age was 69.0±12.6 years, 61% were male, and median Society of Thoracic Surgeons Predicted Risk of Mortality score was 5.4 [interquartile range, 3.2-8.5].Bioprosthesis mode of failure was stenotic (58% of patients), regurgitant (24%), or mixed (18%). The surgical valve was stented in 75% of patients and stentless in 25%. The surgical valve's internal diameter was ≤19 mm in 45% of cases. A balloon-expandable transcatheter valve was used in 53% of procedures. Baseline aortic valve area and mean gradients were 0.87±0.31 cm 2 and 36±18 mmHg, respectively. These improved after ViV-TAVR to 1.38±0.55 cm 2 and 18±11 mmHg at a median outpatient follow-up of 331 days.Higher postprocedural mean gradients were associated with surgical valves having an internal diameter ≤19 mm (24±13 versus 16±8, P=0.002) and with stented surgical valves (22±11 versus 12±6, P<0.001). Conclusions: ViV-TAVR is an effective option for treating degenerated surgical aortic bioprostheses, with acceptable hemodynamic outcomes. Small surgical valves and stented surgical valves are associated with higher postprocedural gradients.

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

“…Concluding procedural aspects and initial outcomes, it seems to be evident, that VIV-TAVR as a heterogeneous group consisting of different procedures (by means of combinations of surgical and TAVR valves) -with respect to some special cases -basically is safe and provides good or at least acceptable initial hemodynamic results [3,13,16]. Furthermore, it is evident, that VIV-TAVR in small surgical valves as well as stented valves is associated with higher postprocedural gradients [16].…”

“…If not, it must remain a bailout-option for risky patients. The presently available literature does not allow to answer this crucial question conclusively [13][14][15][16][17][18].…”

“…Up to date, there exist no further long-term hemodynamic data in the present literature for further comparison. Most studies dealing with hemodynamic results, end after 1-year of outpatient follow-up [14][15][16]. Accordingly, hemodynamic long-term-follow-up has much more to be elaborated in further studies.…”

“…Up today, there exists only little information concerning mid-term, and no information about long-term durability of VIV-TAVR. The presently available studies contain only limited data, mostly reporting a follow-up limited to one year ( [13][14][15][16]. Recently, a sub-analysis of the PARTNER 2-registry reported 3-year outcomes, but under exclusion of bioprosthetic valves with a labeled diameter less than 21mm [17].…”

Hemodynamic follow‐up after valve‐in‐valve TAVR for failed aortic bioprosthesis

“…3,13,16 Furthermore, it is evident, that VIV-TAVR in small surgical valves as well as stented valves is associated with higher postprocedural gradients. 16 As far as good-but Dvir et al 13 already identified a sore spot in the VIVID. Patients presenting with an internal diameter equal or less 20 mm of the surgical valve showed to have an inferior 1-year survival.…”