Optimising the Haemodynamics of Aortic Valve-in-valve Procedures

Abstract

Bioprosthetic surgical valves are increasingly implanted during cardiac surgery, instead of mechanical valves. These tissue valves are associated with limited durability and as a result transcatheter valve-in-valve procedures are performed to treat failed bioprostheses. A relatively common adverse event of aortic valve-in-valve procedures is residual stenosis. Larger surgical valve size, supra-annular transcatheter heart valve type, as well as higher transcatheter heart valve implantation depth, have all been shown to reduce the incidence of elevated post-procedural gradients. With greater understanding of technical considerations and surgical planning, valve-in-valve procedures could be more effective and eventually may become the standard of care for our increasingly ageing and comorbid population with failed surgical bioprostheses.

Redo‐transcatheter aortic valve replacement with the supra‐annular, self‐expandable Evolut platform: Insights from the Transcatheter valve Therapy Registry

“…Valve hemodynamics are better in SEV valves compared to balloon-expandable valves in native aortic valve TAVR. 21,22 The mean gradients in this analysis were low at 30 days (11.9 ± 6.9 mm Hg) and maintained at 1 year (11.7 ± 6.9 mm Hg). Longer term follow up will be required to completely elucidate the importance and clinical impact of low final gradients in this setting, but extrapolating TAV in SAV data to the current scenario reassures redo-TAVRs role as an option to treat failed THV.…”

“…Valve hemodynamics are better in SEV valves compared to balloon‐expandable valves in native aortic valve TAVR 21,22 . The mean gradients in this analysis were low at 30 days (11.9 ± 6.9 mm Hg) and maintained at 1 year (11.7 ± 6.9 mm Hg).…”

Midterm Degeneration of Transcatheter Heart Valve Device following Valve-in-Valve Transcatheter Aortic Valve Replacement Requiring Repeat Transcatheter Aortic Valve Replacement

“…Intra-annular rather than supra-annular CoreValve leaflets within the SAVR annulus may have resulted in constraining forces on the THV leaflets, leading to earlier degeneration than might otherwise have otherwise been expected. 10 Furthermore, the position of the waist of the THV device at the level of the sewing ring of the failing SAVR meant that there would have been less radial expansive force against the SAVR than would have been provided by the inflow of the device had the THV device been implanted higher in the LVOT. The subsequent device migration may have been a secondary contributing factor to early device failure.…”

Valve-in-Valve Transcatheter Aortic Valve Replacement: Challenges for Now and the Future

“…Understandably, patients at the greatest risk for severe patient prosthesis mismatch following ViV-TAVR were those arriving with structural valve deterioration following previous SAVR complicated by severe patient prosthesis mismatch [41,45]. Severe patient prosthesis mismatch prior to ViV-TAVR displays higher 30day and 1-year mortality [46]. Such clear findings again re-highlight the absolute importance of appropriate, far-sighted primary aortic valve intervention.…”