Reinterventions after freestyle stentless aortic valve replacement: an assessment of procedural risks

Abstract

OBJECTIVES Repeat aortic valve interventions after previous stentless aortic valve replacement (AVR) are considered technically challenging with an increased perioperative risk, especially after full-root replacement. We analysed our experience with reinterventions after stentless AVR. METHODS A total of 75 patients with previous AVR using a Freestyle stentless bioprosthesis (31 subcoronary, 15 root-inclusion and 29 full-root replacement) underwent reintervention in our centre from 1993 until December 2018. Periprocedural data were retrospectively collected from the department database and follow-up data were prospectively collected. RESULTS Median age was 62 years (interquartile range 47–72 years). Indications for reintervention were structural valve deterioration (SVD) in 47, non-SVD in 13 and endocarditis in 15 patients. Urgent surgery was required in 24 (32%) patients. Reinterventions were surgical AVR in 16 (21%), root replacement in 51 (68%) and transcatheter AVR in 8 (11%) patients. Early mortality was 9.3% (n = 7), but decreased to zero in the past decade in 28 patients undergoing elective reoperation. Per indication, early mortality was 9% for SVD, 8% for non-SVD and 13% for endocarditis. Aortic root replacement had the lowest early mortality rate (6%), followed by surgical AVR (13%) and transcatheter AVR (25%, 2 patients with coronary artery obstruction). Pacemaker implantation rate was 7%. Overall survival rate at 10 years was 69% (95% confidence interval 53–81%). CONCLUSIONS Repeat aortic valve interventions after stentless AVR carry an increased, but acceptable, early mortality risk. Transcatheter valve-in-valve procedures after stentless AVR require careful consideration of prosthesis leaflet position to prevent obstruction of the coronary arteries.

Transcatheter valve‐in‐valve implantation versus surgical redo aortic root replacement in patients with degenerated freestyle aortic bioprosthesis

“…In the latter study, 30‐day mortality rate was 0% with one patient requiring intraprocedural percutaneous coronary intervention of the left main because of obstruction. Coronary obstruction, which has also been described in a different case series of eight patients with degenerated FSB during VIV TAVI is a severe complication and is often associated with fatal outcome 13 . Using VARC‐2 composite endpoints, Huczek and colleagues 14 previously documented a device success of only 50% in a heterogeneous cohort of 20 patients with degenerated stentless bioprosthesis (including 8 patients with FSB) and an early safety rate of 74% at 30 days after intervention.…”

Long-term results of aortic valve replacement with xenogenic pericardial stentless prosthesis BioLAB KB/A

“…Schneider AW, et al (2019) определили две основных причины для повторной операции после первичного протезирования АК БКП Medtronic Freestyle: тканевая дегенерация (n=97,68%) и протезный эндокардит (n=46,32%). Интервал между имплантацией бескаркасного клапана и повторной операцией составил 9,0 (5,(4)(5)(6)(7)(8)(9)(10)(11)8) лет. Этот период был значительно короче для пациентов с протезным эндокардитом -4,1 (1,8, 7,1) vs 10,4 (8,1, 12,4) лет для пациентов со структурной дисфункцией [11].…”

“…В исследовании не было ни одного пациента с протезом маленького размера (≤21 мм). Schneider AW, et al (2019) тоже ре-комендуют относиться к эндоваскулярному репротезированию с особым вниманием, т. к. бескаркасные протезы не имеют рентгенконтрастного ориентира и при транскатетерном вмешательстве нужно быть очень осторожным, чтобы не допустить обтурации створками биопротеза коронарных устьев [11]. Важно знать, что геометрия корня аорты играет ключевую роль в возникновении этого опасного для жизни осложнения.…”

Incidence, Risk Factors, and Outcomes of Coronary Obstruction Following Valve-in-Valve Transcatheter Aortic Valve Replacement

“…Urgent percutaneous coronary intervention (PCI) was performed in 39 (79.4%) subjects and succeed in 27(69.2%). 26) *** ** ** Akodad, et al 24) *** * ** Camboni, et al 27) *** * ** Ye, et al 28) *** ** ** Grubitzsch, et al 29) **** * *** Schneider , et al 30) *** ** ** Tchétché, et al 31) *** ** ** Miller, et al 14) *** * ** Adamo, et al 13) *** * *** Wernly, et al 32) **** * ** Mosquera, et al 33) *** * *** Ribeiro, et al 10) *** ** ** Webb, et al 34) **** ** **…”