Editorial Comment: Re-operation: a thing of the past? Transcatheter aortic valve-in-valve implantation for failed surgical bioprosthesis

Abstract

Transcatheter aortic valve implantation (TAVI) has become a reliable treatment modality for aortic valve stenosis. More than 10 years after the first implantation, it is still debatable which patients may benefit from TAVI compared with surgical aortic valve replacement (SAVR) although the Partner A study [1] described a well-defined patient population as optimal candidates for TAVI. Evidence for further indications is still needed. Aortic valve re-operation may carry a higher perioperative risk compared with first-time SAVR because patients are older but technically speaking, redo-SAVR is not extremely demanding [2]. Transcatheter aortic valve-in-valve implantation (ViV TAVI) might be of particular interest for some patients scheduled for SAVR as a redo-procedure, for instance, in those with patent coronary artery grafts. The present study [3], which was sponsored by Medtronic, reports on 18 patients from three different centres in Germany who received a CoreValve™ ViV TAVI to treat a degenerated aortic bioprosthetic valve. Including patients older than 75 years with either a logistic EuroSCORE of ≥15% or one additional self-defined risk factor (i.e., atrial fibrillation) might appear rather arbitrary. But with an overall logistic EuroSCORE of 34%, patient selection seems adequate. Unfortunately, more accurate STS scores are lacking. Procedural success was achieved when echocardiography showed adequate valve placement and function at discharge or on POD 10 without any composite Major Adverse Outcomes (MAE) until discharge. Indications for TAVI in the presence of a degenerated tissue valve were isolated regurgitation in 33% of patients, isolated stenosis in 28% and a combination of both in 39%. The average time interval since primary AVR was 7 years (range 1–16 years). Valve-in-valve TAVI represents an attractive and less invasive alternative to conventional redo-surgery and some technical details, as, for instance, the radio-opaque frame of the in situ tissue valve facilitates accurate valve-in-valve deployment. Moreover, fluoroscopic orientation requires smaller doses of contrast and also allows for ViV implantation in pure regurgitation of the tissue valve. Sizing is easier because the diameter of the prior valve is usually known from the time of surgery. Finally,