Valve-in-valve transcatheter aortic valve replacement: the challenge of the next future

Abstract

In recent years, an increasing number of bioprostheses have been implanted, and in the near future more and more patients will be candidates for reoperation due to structural deterioration of the valve. Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has become a safe and effective alternative to surgery and is currently approved for higher-risk, inoperable patients. From the most recent studies, early mortality has decreased and improvements in symptoms and quality of life of treated patients have been documented. ViV TAVR is a complex procedure that can present many pitfalls and therefore must be performed in high volume centers and with experienced staff because the risk of peri- and post-procedural complications is much higher than TAVR on native valve. In this review, we analyze the main procedural issues reported in the literature during ViV TAVR procedures: elevated postprocedural gradients, coronary obstruction and thrombosis of the leaflets of the bioprosthesis. Because of the opening of TAVR to younger and younger patients, thus with a longer life expectancy than the durability of the bioprosthesis, the next challenge will be the management of the lifetime strategy of patients with aortic stenosis, as the first type of intervention will influence all future therapeutic choices of our patient.

Transcatheter Aortic Valve Replacement for Failed Surgical or Transcatheter Bioprosthetic Valves: A Comprehensive Review

“…Predictors of coronary obstruction in ViV TAVR are dependent on both the degenerated THV or bioprosthetic valve and the native aortic anatomy [ 61 ]. Narrow sinotubular junction, narrow sinuses of Valsalva, low coronary ostia, and previous aortic root surgery are all examples of aortic anatomy that may increase the risk of coronary obstruction [ 61 , 62 ]. Bioprosthetic surgical valves with externally mounted leaflets are more likely to cause coronary obstruction during TAV-in-SAV due to the close proximity of the leaflets to the coronary arteries [ 61 ].…”

“…Bioprosthetic surgical valves with externally mounted leaflets are more likely to cause coronary obstruction during TAV-in-SAV due to the close proximity of the leaflets to the coronary arteries [ 61 ]. Stentless bioprosthetic valves and valves with bulky or outward-extending leaflets may also increase the likelihood of coronary obstruction [ 61 , 62 ]. When a THV is implanted during ViV TAVR, bioprosthetic leaflets from the prior SAV are tilted upward, creating a tunnel of tissue often described as a neo-skirt that could potentially lead to coronary obstruction that restricts future coronary access [ 61 , 63 ].…”

“…When a THV is implanted during ViV TAVR, bioprosthetic leaflets from the prior SAV are tilted upward, creating a tunnel of tissue often described as a neo-skirt that could potentially lead to coronary obstruction that restricts future coronary access [ 61 , 63 ]. During TAV-in-TAV placement, intra-annular leaflet positioning may be preferable for reduced coronary obstruction and better coronary re-access, but there are no clear data trends established to determine if this benefit outweighs the risk of PPM and paravalvular leak [ 61 , 62 , 63 ].…”

Comparison of in-hospital outcomes and long-term survival for valve-in-valve transcatheter aortic valve replacement versus the benchmark native valve transcatheter aortic valve replacement procedure

“…However, a high residual gradient following the VIV-TAVR procedure remains a real concern. Pre-existing prosthesis-patient mismatch, small effective orifice area, and deep valve implant were identified as strong predictors, while supra-annular valve type and high transcatheter heart valve implant were associated with risk reduction ( 19 ). In addition, a decrease in mean residual gradient and an improvement in mean aortic valve area were associated with bioprosthetic valve fracture in the context of VIV-TAVR for patients with degenerated bioprosthetic valves ( 20 ).…”