Transcatheter valve-in-valve implantation in degenerated aortic bioprostheses: are patients with small surgical bioprostheses at higher risk for unfavourable mid-term outcomes?

Abstract

Background: To examine outcomes of valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) according to the inner diameter (ID) of the degenerated aortic valve bioprosthesis. Methods: We analyzed survival, stroke, permanent pacemaker (PPM) implantation, paravalvular (PV) leakage, acute kidney injury and vascular complications in fifty-nine patients during a ten-year period. Patients were stratified according to the ID of the indwelling degenerated biological aortic valve (true ID ≤ and >20 mm). Differences in post-procedural transvalvular gradients and hospital re-admissions were analyzed. Results: The median age of the small diameter group and large diameter group was eighty-one and eighty years, respectively. Median logistic EuroSCORE I was 23.9% and 26.2% and median Society of Thoracic Surgeons (STS) score was 5.7% and 7.8% for the small and large groups, respectively. Survival, stroke, PPM implantation, PV leakage, acute kidney injury and vascular complications did not reach any statistically significant difference between both groups. Postprocedural transvalvular gradients differed significantly according to the true ID of the degenerated bioprosthetic valve and consequently of the respective TAVI valve. There was a significant difference with regard to hospital readmissions according to the true ID. Conclusions: TAVI ViV implantation for aortic bioprostheses with small true IDs of ≤20 mm is associated with comparable mid-term mortality and periprocedural stroke rate compared to implantation into larger bioprostheses. However, the periprocedural and mid-term transvalvular gradients, as well as hospital re-admission rates are significantly higher in the small diameter group.

Report on outcomes of valve-in-valve transcatheter aortic valve implantation and redo surgical aortic valve replacement in the Netherlands

“…Furthermore, residual gradient and patient-prosthesis mismatch are relevant issues that can likely be attributed to underexpansion of the TAVI valve [ 18 ]. Especially patients with small bioprostheses (< 21 mm) are challenging in terms of haemodynamic performance after ViV-TAVR [ 23 ]. Interesting efforts using surgical bioprosthetic valve fracture to improve expansion of the TAVI valve are currently being explored but are not yet routinely practised [ 24 ].…”

Recent Outcomes of Surgical Redo Aortic Valve Replacement in Prosthetic Valve Failure

“…regarding the mid-and long-term results of ViV-TAVI because of the higher postoperative pressure gradient compared to surgery (14,15). Regarding that ViV-TAVI is challenging in patients with small bioprostheses (<21mm) in terms of hemodynamic performance (16) and…”

“…There has been concern regarding the mid-and long-term results of ViV-TAVI because of the higher postoperative pressure gradient compared with surgery. 14,15 Regarding that, ViV-TAVI is challenging in patients with small bioprostheses (<21 mm) in terms of hemodynamic performance 16 and Asians are tend to implant smaller bioprostheses at the index procedure. In our study, 290 patients (89.5%) had bioprostheses less than or equal to 21 mm.…”

Valve-in-valve procedures for degenerated surgical and transcatheter aortic valve bioprostheses using a latest-generation self-expanding intra-annular transcatheter heart valve

“…Therefore, this technique was implemented in international guidelines for treatment of valvular heart disease ( 3 , 4 ). However, certain drawbacks of this procedure were especially described concerning suboptimal hemodynamic results in patients with small bioprostheses or risk of coronary occlusion in patients with low coronary ostia take-off ( 5 , 6 ). In the past, several procedural steps were introduced to overcome these possible complications including bioprosthetic valve fracture (BVF) to optimize hemodynamic results and intentional leaflet laceration to mitigate the risk of coronary occlusion ( 7 , 8 ).…”