Unique technical challenges in patients undergoing TAVR for failed aortic homografts

Abstract

Objective: Surgical reoperation for aortic homograft structural valve degeneration (SVD) is a high-risk procedure. Transcatheter aortic valve replacement (TAVR) for homograft-SVD is an alternative to reoperation, but descriptions of implantation techniques are limited. This study compares outcome in patients undergoing into two groups by the type of previously implanted aortic valve prosthesis: TAVR for failed aortic homografts (TAVR-H) or for stented aortic bioprostheses (TAVR-BP). Methods: From 2015 to 2017, TAVR was performed in 41 patients with SVD. Thirty-three patients in the TAVR-BP group (six for SVD of valved conduits), and eight patients in the TAVR-H group. The Valve Academic Research Consortium criteria were used for outcome reporting purposes. Results: The patients with TAVR-BP had predominant prosthetic stenosis (94%, p = .002), whereas TAVR-H individuals presented mostly with regurgitation (88%, p = <.001). Patients with TAVR-H received: Sapien-3 (6), Sapien-XT (1), and CoreValve (1) devices. Low, 40% ventricular fixation in relation to homograft annulus was attempted to anchor the prosthesis on the homograft sutureline. One patient with TAVR-BP experienced intraoperative distal prosthesis migration and Type-B aortic dissection, and two patients in the TAVR-H group had late postoperative proximal device migration. In both groups, there was zero 30-day mortality, stroke, or pacemaker implantation. Conclusions: TAVR for failing aortic homografts may be a feasible and safe alternative to high-risk surgical reintervention. Precise, 40%-ventricular device positioning appears crucial for prevention of late paravalvular leak/late prosthesis migration and minimizing the risk of repeat surgical intervention.

Transcatheter Aortic Valve Implantation in a Patient With Degenerated Aortic Homograft and Anomalous Right Coronary Artery Originating From Left Aortic Sinus

“…Kislitsina et al. 3 compared the outcomes of 41 patients undergoing TAVI because of aortic valve degeneration, 33 with failed stented aortic bioprostheses and eight with failed homografts. The bioprosthesis group presented predominantly with prosthesis stenosis (94%, P = .002), whereas the homograft group showed mostly aortic regurgitation (88%, P < .001).…”

Failed bioprosthetic valve approaches: Transcatheter aortic valve replacement approach

“…Homograft failure typically results in aortic regurgitation and the implant technique for aortic VIV is not established, owing to the variability of the proximal suture line of the homograft. 20 On the other hand, reoperation for failed homograft is more challenging than for failed AVR owing to homograft calcification, which is often severe. Comparative studies have paralleled those for aortic VIV for stented bioprosthesis in terms of early mortality and perioperative complications, 21 but some centers including ours have shown that late valve migration may be a concern.…”

“…Comparative studies have paralleled those for aortic VIV for stented bioprosthesis in terms of early mortality and perioperative complications, 21 but some centers including ours have shown that late valve migration may be a concern. 20 Thus, although aortic VIV for failed aortic homografts is feasible, long-term outcomes deserve attention.…”

The Sutureless Biological Bentall Procedure: A New Technique to Create a Modular Valve-Conduit Construct

“…Transcatheter AVR (TAVR) may be a less risky approach in the absence of infection for both homografts or xenografts and bioprosthetic valve composite conduits, but long-term results will have to follow, particularly in the young patient. 20,21 The development of a modular biological prosthetic valvesynthetic graft conduit would provide a technical advancement for the BioBentall. A simplified technique should minimize risk not only at the time of the primary operation but also at the time of an inevitable reintervention due to structural valve deterioration.…”

“…Transcatheter AVR (TAVR) may be a less risky approach in the absence of infection for both homografts or xenografts and bioprosthetic valve composite conduits, but long-term results will have to follow, particularly in the young patient. 20,21…”