Transcatheter Valve-in-Valve Implantation for Failed Surgical Bioprosthetic Valves

Abstract

When bioprosthetic cardiac valves fail, reoperative valve replacement carries a higher risk of morbidity and mortality compared with initial valve replacement. Transcatheter heart valve implantation may be a viable alternative to surgical aortic valve replacement for high-risk patients with native aortic stenosis, and valve-in-valve (V-in-V) implantation has been successfully performed for failed surgical bioprostheses in the aortic, mitral, pulmonic, and tricuspid positions. Despite some core similarities to transcatheter therapy of native valve disease, V-in-V therapy poses unique clinical and anatomic challenges. In this paper, we review the challenges, selection criteria, techniques, and outcomes of V-in-V implantation.

Transcatheter Aortic and Mitral Valve‐in‐Valve Implantation Using the Edwards Sapien 3 Heart Valve

“…An inadequately expanded THV may be at risk of elevated transvalvular gradient because of inadequate leaflet expansion and mobility, also potentially increasing the risk of accelerated leaflet degeneration 1, 2, 4, 11…”

“…An important component of performing the VIV procedure starts with an in‐depth understanding of the failed bioprosthetic valve, which includes the following: the type of valve used (stented, stentless, sutureless, transcatheter valve), its structural elements, the technical details of the primary valve surgery (intra‐annular versus supra‐annular), and the cause of bioprosthetic valve failure (wear and tear, calcification, endocarditis, thrombosis, leaflet dysfunction, and pannus formation) 1, 2, 4, 5, 12. Selection of the THV size for the aortic and mitral VIV implantation depends on many factors listed above.…”

“…The sizing and labeling of the surgical bioprosthetic valves are not standardized and vary widely based on the different manufacturers. The minimum internal diameter of the surgical bioprosthetic valve may vary markedly from the given labeled valve size1, 2, 4, 5 (Figure 1); label size alone is therefore not suitable as a guide to THV size selection.…”

“…The “true” inner diameter (T‐ID) of the surgical bioprosthesis is one of the most important pieces of information needed for selecting the size of the THV for the aortic or mitral VIV procedure 4. It is important to note that most bioprosthetic valves have a “stent” inner diameter, which consists of the frame/skeleton of the valve, including the overlying fabric, and the T‐ID, which takes into account the leaflets sewn within the valve frame13 (Figure 1).…”

“…In contrast to mechanical valves, the use of bioprosthetic valves to treat significant aortic valve stenosis (AS) or aortic valve regurgitation (AR) in the native aortic valve has continued to increase over time 1, 2. Bioprosthetic valves are advantageous to patients as they negate the need for long‐term anticoagulation therapy; however, they have limited durability and are expected to degenerate within 5 to 20 years 2, 3, 4. The current standard of care for patients with a degenerated bioprosthetic valve is surgical valve replacement; however, the morbidity and mortality for reoperation is significant because of the technical complexity of the re‐do sternotomy, and also because most of these patients are elderly with multiple comorbid conditions such as prior coronary artery bypass surgery, diabetes mellitus, and cerebrovascular disease 2, 5, 6…”