Failed bioprosthetic valve approaches: Transcatheter aortic valve replacement approach

Abstract

Central MessageThe transcatheter aortic valve replacement approach to failed bioprosthetic valves is favored over reoperative aortic valve replacement because of improved mortality and morbidity.This Invited Expert Opinion provides a perspective on the following paper: Source article: J Am Coll Cardiol. 2020 Aug 4;76(5):489-499. https://doi.org/10.1016/j.jacc.2020.06.010.See Commentaries on pages 1799, 1800, and 1802. The transcatheter aortic valve replacement approach to failed bioprosthetic valves is favored over reoperative aortic valve replacement because of improved mortality and morbidity. This Invited Expert Opinion provides a perspective on the following paper: Source article: J Am Coll Cardiol. 2020 Aug 4;76(5):489-499. https://doi.org/10.1016/j.jacc.2020.06.010. See Commentaries on pages 1799, 1800, and 1802. Bioprosthetic valves will fail, given enough time. All prosthetic valves, whether mechanical or biological, are beset with nonstructural valve deterioration due to such causes as infective endocarditis and pannus formation, but bioprosthetic valves are uniquely prone to structural valve deterioration (SVD) caused by calcification or wear, leading to either stenosis or regurgitation (Figure 1, A and B).1Dvir D. Bourguignon T. Otto C.M. Hahn R.T. Rosenhek R. Webb J.G. et al.Standardized definition of structural valve degeneration for surgical and transcatheter bioprosthetic aortic valves.Circulation. 2018; 137: 388-399Google Scholar The combination of SVD and non-SVD constitutes what is now termed bioprosthetic valve failure (BVF).2Kappetein A.P. Head S.J. Généreux P. Piazza N. van Mieghem N.M. Blackstone E.H. et al.Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document.J Am Coll Cardiol. 2012; 60: 1438-1454Google Scholar A transcatheter approach to SVD using the valve-in-valve (VIV) procedure is now well accepted for the treatment of SVD. But should aortic VIV be the preferred procedure for most patients? Reoperative cardiac surgery with repeat aortic valve replacement (AVR) was once the only therapeutic option for BVF, but the operative risk of reoperative AVR is not negligible. Over the last 2 decades, reported 30-day mortality for reoperative AVR ranged from 3.5% to 8.4%.3Kaneko T. Loberman D. Gosev I. Rassam F. McGurk S. Leacche M. et al.Reoperative aortic valve replacement in the octogenarians—minimally invasive technique in the era of transcatheter valve replacement.J Thorac Cardiovasc Surg. 2014; 147: 155-162Google Scholar, 4LaPar D.J. Yang Z. Stukenborg G.J. Peeler B.B. Kern J.A. Kron I.L. et al.Outcomes of reoperative aortic valve replacement after previous sternotomy.J Thorac Cardiovasc Surg. 2010; 139: 263-272Google Scholar, 5Leontyev S. Borger M.A. Davierwala P. Walther T. Lehmann S. Kempfert J. et al.Redo aortic valve surgery: early and late outcomes.Ann Thorac Surg. 2011; 91: 1120-1126Google Scholar Moreover, the morbidity of the operation included stroke (1.2%), renal failure (5.6%), prolonged intubation (16.7%), reoperation for bleeding (5.6%), and deep sternal wound infection (0.6%).6Potter D.D. Sundt III, T.M. Zehr K.J. Dearani J.A. Daly R.C. Mullany C.J. et al.Operative risk of reoperative aortic valve replacement.J Thorac Cardiovasc Surg. 2005; 129: 94-103Google Scholar Most patients requiring reoperative AVR were rightfully considered high risk, and after the approval of transcatheter aortic valve replacement (TAVR) for native aortic stenosis, many clinicians looked to failing bioprosthetic valves as the next area in which to expand TAVR indications.7Webb J.G. Dvir D. Transcatheter aortic valve replacement for bioprosthetic aortic valve failure: the valve-in-valve procedure.Circulation. 2013; 127: 2542-2550Google Scholar The aortic VIV procedure is TAVR for the treatment of failing bioprosthetic valves, which has become a reasonable alternative to reoperative AVR. The procedure takes advantage of the stent frame of the failing bioprosthesis by anchoring into a uniformly rigid structure that is often visible on fluoroscopy (Figure 1, C and D). Currently, both balloon-expandable and self-expanding transcatheter heart valves (THVs) are commercially approved for patients with BVF who are otherwise high risk for reoperative AVR, and their use is supported by current clinical practice guidelines (class of recommendation IIa).8Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Fleisher L.A. et al.2017 AHA/ACC focused update of the 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.J Am Coll Cardiol. 2017; 70: 252-289Google Scholar,9Baumgartner H. Falk V. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791Google Scholar The aortic VIV procedure has become increasingly safer over time.10Tuzcu E.M. Kapadia S.R. Vemulapalli S. Carroll J.D. Holmes Jr., D.R. Mack M.J. et al.Transcatheter aortic valve replacement of failed surgically implanted bioprostheses: the STS/ACC Registry.J Am Coll Cardiol. 2018; 72: 370-382Google Scholar The use of first-generation THVs for aortic VIV were associated with significant 30-day mortality approaching that of reoperative AVR, owing mostly to poor patient selection and the incomplete understanding of coronary occlusion by the failing bioprosthetic valve leaflets. Second-generation THVs and more rigorous imaging have resulted in a dramatic decline in operative risk, as demonstrated by the reported 30-day all-cause mortality in clinical trials for high-risk patients of 2.7% for balloon-expandable valves and 2.2% for self-expanding valves.11Webb J.G. Mack M.J. White J.M. Dvir D. Blanke P. Herrmann H.C. et al.Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses: PARTNER 2 Valve-in-Valve Registry.J Am Coll Cardiol. 2017; 69: 2253-2262Google Scholar,12Deeb G.M. Chetcuti S.J. Reardon M.J. Patel H.J. Grossman P.M. Schreiber T. et al.One-year results in patients undergoing transcatheter aortic valve replacement with failed surgical bioprostheses.JACC Cardiovasc Interv. 2017; 10: 1034-1044Google Scholar Although most comparative effectiveness studies have shown similar early mortality between groups,13Ejiofor J.I. Yammine M. Harloff M.T. McGurk S. Muehlschlegel J.D. Shekar P.S. et al.Reoperative surgical aortic valve replacement versus transcatheter valve-in-valve replacement for degenerated bioprosthetic aortic valves.Ann Thorac Surg. 2016; 102: 1452-1458Google Scholar, 14Sedeek A.F. Greason K.L. Sandhu G.S. Dearani J.A. Holmes Jr., D.R. Schaff H.V. Transcatheter valve-in-valve vs surgical replacement of failing stented aortic biological valves.Ann Thorac Surg. 2019; 108: 424-430Google Scholar, 15Raschpichler M.C. Woitek F. Chakravarty T. Flint N. Yoon S.H. Mangner N. et al.Valve-in-valve for degenerated transcatheter aortic valve replacement versus valve-in-valve for degenerated surgical aortic bioprostheses: a 3-center comparison of hemodynamic and 1-year outcome.J Am Heart Assoc. 2020; 9: e013973Google Scholar some studies have found that 30-day and long-term survival significantly favor aortic VIV. A multicenter Canadian-based propensity-matched trial showed both lower early mortality (absolute risk reduction ARD, −7.5%; 95% confidence interval [CI], −12.6% to −2.3%) and increased late survival (77% vs 67%; P = .046).16Tam D.Y. Dharma C. Rocha R.V. Ouzounian M. Wijeysundera H.C. Austin P.C. et al.Transcatheter ViV versus redo surgical AVR for the management of failed biological prosthesis: early and late outcomes in a propensity-matched cohort.JACC Cardiovasc Interv. 2020; 13: 765-774Google Scholar A recent French study retrospectively reviewed a matched, even distribution of 1428 patients undergoing aortic VIV or reoperative AVR and showed a lower 30-day mortality in the former group (odds ratio [OR], 0.48; 95% CI, 0.30-0.78).17Deharo P. Bisson A. Herbert J. Lacour T. Saint Etienne C. Porto A. et al.Transcatheter valve-in-valve aortic valve replacement as an alternative to surgical re-replacement.J Am Coll Cardiol. 2020; 76: 489-499Google Scholar Finally, a recent review of the US National Readmission Database showed a significantly lower 30-day mortality in the aortic VIV group (OR, 0.41; 95% CI, 0.23-0.74).18Hirji S.A. Percy E.D. Zogg C.K. Malarczyk A. Harloff M.T. Yazdchi F. et al.Comparison of in-hospital outcomes and readmissions for valve-in-valve transcatheter aortic valve replacement vs reoperative surgical aortic valve replacement: a contemporary assessment of real-world outcomes.Eur Heart J. 2020; 41: 2747-2755Google Scholar Based on these data, early mortality associated with aortic VIV is at least as good as, if not better than, that for reoperative AVR. Not surprisingly, these same studies have shown lower perioperative morbidity after aortic VIV compared with reoperative AVR. Comparative data from the Mayo Clinic clearly demonstrated a reduced rate of major complications after aortic VIV, including a significantly lower risk of procedure-related complications (23% vs 59%; P < .001), prolonged ventilation (3% vs 15%; P = .002), renal failure (4% vs 19%; P < .001), and blood transfusions (12% vs 53%; P < .001) compared with reoperative AVR.14Sedeek A.F. Greason K.L. Sandhu G.S. Dearani J.A. Holmes Jr., D.R. Schaff H.V. Transcatheter valve-in-valve vs surgical replacement of failing stented aortic biological valves.Ann Thorac Surg. 2019; 108: 424-430Google Scholar Another large, propensity-matched analysis showed a significantly lower risk of morbidity in the aortic VIV group (OR, 0.56; 95% CI, 0.43-0.72).18Hirji S.A. Percy E.D. Zogg C.K. Malarczyk A. Harloff M.T. Yazdchi F. et al.Comparison of in-hospital outcomes and readmissions for valve-in-valve transcatheter aortic valve replacement vs reoperative surgical aortic valve replacement: a contemporary assessment of real-world outcomes.Eur Heart J. 2020; 41: 2747-2755Google Scholar Finally, in several studies the median length of stay in the aortic VIV group was approximately half that in the reoperative AVR group, and the median ICU length of stay was significantly shorter in the former group (0 vs 68 hours; P = .001).13Ejiofor J.I. Yammine M. Harloff M.T. McGurk S. Muehlschlegel J.D. Shekar P.S. et al.Reoperative surgical aortic valve replacement versus transcatheter valve-in-valve replacement for degenerated bioprosthetic aortic valves.Ann Thorac Surg. 2016; 102: 1452-1458Google Scholar,16Tam D.Y. Dharma C. Rocha R.V. Ouzounian M. Wijeysundera H.C. Austin P.C. et al.Transcatheter ViV versus redo surgical AVR for the management of failed biological prosthesis: early and late outcomes in a propensity-matched cohort.JACC Cardiovasc Interv. 2020; 13: 765-774Google Scholar,19Patel P.M. Chiou E. Cao Y. Binogo J. Guyton R.A. Leshnower B. et al.Isolated redo-aortic valve replacement versus valve-in-valve transcatheter valve replacement.Ann Thorac Surg. October 28, 2020; ([Epub ahead of print])Google Scholar Rhythm disturbances including heart block requiring permanent pacemaker and new-onset atrial fibrillation appear to be less frequent after aortic VIV than after reoperative AVR. Conceptually, the risk of heart block after aortic VIV should not be significantly elevated, because the THV is anchored within the surgical bioprosthesis and not the native aortic annulus. Notably, the rate of pacemaker implantation after aortic VIV is indeed lower as compared with TAVR for native AS (3% vs 10.9%; P < .001).10Tuzcu E.M. Kapadia S.R. Vemulapalli S. Carroll J.D. Holmes Jr., D.R. Mack M.J. et al.Transcatheter aortic valve replacement of failed surgically implanted bioprostheses: the STS/ACC Registry.J Am Coll Cardiol. 2018; 72: 370-382Google Scholar However, comparative data regarding heart block following aortic VIV versus reoperative AVR is less definitive, but also suggests a significantly lower rate of permanent pacemaker (absolute risk reduction, −9.8%; 95% CI, −16.1% to −3.4%) following aortic VIV.16Tam D.Y. Dharma C. Rocha R.V. Ouzounian M. Wijeysundera H.C. Austin P.C. et al.Transcatheter ViV versus redo surgical AVR for the management of failed biological prosthesis: early and late outcomes in a propensity-matched cohort.JACC Cardiovasc Interv. 2020; 13: 765-774Google Scholar It is already well known that new-onset atrial fibrillation occurs less frequently after TAVR than SAVR for native AS. A recent multicenter study showed a similar effect after aortic VIV with a lower risk of new-onset atrial fibrillation following aortic VIV (0.6% vs 4.0%; OR, 0.13; 95% CI, 0.05-0.38).17Deharo P. Bisson A. Herbert J. Lacour T. Saint Etienne C. Porto A. et al.Transcatheter valve-in-valve aortic valve replacement as an alternative to surgical re-replacement.J Am Coll Cardiol. 2020; 76: 489-499Google Scholar Taken as a whole, aortic VIV demonstrates improving safety in terms of both 30-day mortality, major morbidity and rhythm disturbance when compared with reoperative AVR. A special subset of patients are those with failing aortic homografts or stentless bioprosthesis. 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.20Kislitsina O.N. Szlapka M. McCarthy P.M. Davidson C.J. Flaherty J.D. Sweis R.N. et al.Unique technical challenges in patients undergoing TAVR for failed aortic homografts.J Card Surg. 2021; 36: 89-96Google Scholar 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,21Sedeek A.F. Greason K.L. Nkomo V.T. Eleid M.F. Maltais S. Williamson E.E. et al.Repeat aortic valve replacement for failing aortic root homograft.J Thorac Cardiovasc Surg. 2019; 158: 378-385.e2Google Scholar but some centers including ours have shown that late valve migration may be a concern.20Kislitsina O.N. Szlapka M. McCarthy P.M. Davidson C.J. Flaherty J.D. Sweis R.N. et al.Unique technical challenges in patients undergoing TAVR for failed aortic homografts.J Card Surg. 2021; 36: 89-96Google Scholar Thus, although aortic VIV for failed aortic homografts is feasible, long-term outcomes deserve attention. Coronary obstruction is a limitation of aortic VIV and occurs when the frame of the THV pushes the leaflets of the old bioprosthetic valve into a cylindrical configuration.22Dvir D. Webb J. Brecker S. Bleiziffer S. Hildick-Smith D. Colombo A. et al.Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in-valve registry.Circulation. 2012; 126: 2335-2344Google Scholar Risk factors include sinus effacement (so-called “stovepipe” root) and the design of bioprosthetic valves (internally vs externally wrapped design). Coronary obstruction is typically treated with emergency coronary stenting and less frequently with emergency coronary artery bypass grafting with or without mechanical circulatory support.23Ribeiro H.B. Rodés-Cabau J. Blanke P. Leipsic J. Kwan Park J. Bapat V. et al.Incidence, predictors, and clinical outcomes of coronary obstruction following transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: insights from the VIVID registry.Eur Heart J. 2018; 39: 687-695Google Scholar Appropriate patient selection using advanced imaging has reduced the risk of coronary obstruction which is now <1%.24Dvir D. Leipsic J. Blanke P. Ribeiro H.B. Kornowski R. Pichard A. et al.Coronary obstruction in transcatheter aortic valve-in-valve implantation: preprocedural evaluation, device selection, protection, and treatment.Circ Cardiovasc Interv. 2015; 8: e002079Google Scholar A solution for those patients at risk for coronary obstruction is the bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure.25Khan J.M. Greenbaum A.B. Babaliaros V.C. Rogers T. Eng M.H. Paone G. et al.The BASILICA trial: prospective multicenter investigation of intentional leaflet laceration to prevent TAVR coronary obstruction.JACC Cardiovasc Interv. 2019; 12: 1240-1252Google Scholar The BASILICA procedure is performed at the same setting as aortic VIV but just before valve implantation. In this procedure, the leaflet of the surgical bioprosthesis is lacerated with an energized wire to expose the coronary artery os and can be repeated for both coronary leaflets. The reported outcomes after BASILICA show effectiveness of the procedure (93%), but at the cost of increased stroke (10%).25Khan J.M. Greenbaum A.B. Babaliaros V.C. Rogers T. Eng M.H. Paone G. et al.The BASILICA trial: prospective multicenter investigation of intentional leaflet laceration to prevent TAVR coronary obstruction.JACC Cardiovasc Interv. 2019; 12: 1240-1252Google Scholar Of note, unplanned intervention and procedural mortality after BASILICA were both zero and only a single mortality (3%) was recorded at 30 days.25Khan J.M. Greenbaum A.B. Babaliaros V.C. Rogers T. Eng M.H. Paone G. et al.The BASILICA trial: prospective multicenter investigation of intentional leaflet laceration to prevent TAVR coronary obstruction.JACC Cardiovasc Interv. 2019; 12: 1240-1252Google Scholar Thus, current data has established reasonable safety of the BASILICA with aortic VIV, especially in patients who are not candidates for reoperative AVR. The stent of the bioprosthetic valve affords a reliable landing zone for the THV but at the same time is another limitation of the aortic VIV procedure. The implanted THV can expand no larger than the stent of the failing bioprosthetic valve, a problem not relevant to reoperative AVR, where the failing bioprosthesis is removed. The implantation of a smaller valve can result in patient–prosthesis mismatch (PPM). The mean gradient after aortic VIV has been reported to be 17-18 mmHg for both balloon-expandable and self-expanding THV.11Webb J.G. Mack M.J. White J.M. Dvir D. Blanke P. Herrmann H.C. et al.Transcatheter aortic valve implantation within degenerated aortic surgical bioprostheses: PARTNER 2 Valve-in-Valve Registry.J Am Coll Cardiol. 2017; 69: 2253-2262Google Scholar,12Deeb G.M. Chetcuti S.J. Reardon M.J. Patel H.J. Grossman P.M. Schreiber T. et al.One-year results in patients undergoing transcatheter aortic valve replacement with failed surgical bioprostheses.JACC Cardiovasc Interv. 2017; 10: 1034-1044Google Scholar Smaller bioprosthetic valves are at increased risk for PPM after aortic VIV compared with larger valve sizes. Furthermore, PPM is associated with reduced survival, increased readmission rates, and late structural valve deterioration.26Fallon J.M. DeSimone J.P. Brennan J.M. O'Brien S. Thibault D.P. DiScipio A.W. et al.The incidence and consequence of prosthesis–patient mismatch after surgical aortic valve replacement.Ann Thorac Surg. 2018; 106: 14-22Google Scholar,27Flameng W. Herregods M.C. Vercalsteren M. Herijgers P. Bogaerts K. Meuris B. Prosthesis–patient mismatch predicts structural valve degeneration in bioprosthetic heart valves.Circulation. 2010; 121: 2123-2129Google Scholar Although patient selection can reduce the risk of PPM after aortic VIV, many patients after aortic VIV will be exposed to elevated gradients, which may affect long-term outcome.28Webb J.G. Murdoch D.J. Alu M.C. Cheung A. Crowley A. Dvir D. et al.3-Year outcomes after valve-in-valve transcatheter aortic valve replacement for degenerated bioprostheses: the PARTNER 2 Registry.J Am Coll Cardiol. 2019; 73: 2647-2655Google Scholar During aortic VIV, the risk of PPM can be mitigated by fracturing the stent of the bioprosthetic valve. The valve fracture (VF) technique is performed by inflating a high-pressure balloon (sometimes >20 ATM) within the frame of the surgical bioprosthesis either before or after THV implantation and can increase valve diameter by up to 4 mm.29Allen K.B. Chhatriwalla A.K. Cohen D.J. Saxon J.T. Aggarwal S. Hart A. et al.Bioprosthetic valve fracture to facilitate transcatheter valve-in-valve implantation.Ann Thorac Surg. 2017; 104: 1501-1508Google Scholar Although not recommended by THV manufacturers, the procedure has been associated with a decrease in valve gradients of 10.9 mmHg and increase in effective valve area by 0.7 cm2 with acceptable procedural safety (30-day mortality, 2.7%).30Allen K.B. Chhatriwalla A.K. Saxon J.T. Cohen D.J. Nguyen T.C. Webb J. et al.Bioprosthetic valve fracture: technical insights from a multicenter study.J Thorac Cardiovasc Surg. 2019; 158: 1317-1328.e1Google Scholar The concept of bioprosthetic valve stent expansion is also currently featured in a commercially available surgical bioprosthetic valve.31Puskas J.D. Bavaria J.E. Svensson L.G. Blackstone E.H. Griffith B. Gammie J.S. et al.The COMMENCE trial: 2-year outcomes with an aortic bioprosthesis with RESILIA tissue.Eur J Cardiothorac Surg. 2017; 52: 432-439Google Scholar Overall, elevated gradients and PPM continues to be a limitation of aortic VIV, but VF with high-pressure balloon is an attractive solution especially in bioprosthetic valves amenable to stent fracture. The durability of THV used during aortic VIV remains unknown. Patients at high risk for reoperative AVR may never see the long-term benefit of valve durability due to poor overall survival (estimated to be 66% at 5 years), making aortic VIV a reasonable alternative to reoperative AVR in this cohort of patients.5Leontyev S. Borger M.A. Davierwala P. Walther T. Lehmann S. Kempfert J. et al.Redo aortic valve surgery: early and late outcomes.Ann Thorac Surg. 2011; 91: 1120-1126Google Scholar,8Nishimura R.A. Otto C.M. Bonow R.O. Carabello B.A. Erwin III, J.P. Fleisher L.A. et al.2017 AHA/ACC focused update of the 2014 AHA/ACC Guideline for the management of patients with valvular heart disease: a report of the American College of Cardiology/American Heart Association task force on clinical practice guidelines.J Am Coll Cardiol. 2017; 70: 252-289Google Scholar,9Baumgartner H. Falk V. Bax J.J. De Bonis M. Hamm C. Holm P.J. et al.2017 ESC/EACTS guidelines for the management of valvular heart disease.Eur Heart J. 2017; 38: 2739-2791Google Scholar The durability of THV is more pertinent to lower risk and younger patients and this important endpoint will be followed out to 10 years in the low-risk, randomized trials for native AS.32Mack M.J. Leon M.B. Thourani V.H. Makkar R. Kodali S.K. Russo M. et al.Transcatheter aortic-valve replacement with a balloon-expandable valve in low-risk patients.N Engl J Med. 2019; 380: 1695-1705Google Scholar,33Popma J.J. Deeb G.M. Yakubov S.J. Mumtaz M. Gada H. O'Hair D. et al.Transcatheter aortic-valve replacement with a self-expanding valve in low-risk patients.N Engl J Med. 2019; 380: 1706-1715Google Scholar In addition, a currently enrolled trial for low-risk and intermediate-risk patients undergoing aortic VIV has planned 10-year follow-up and the investigators will report 1-year outcomes in early 2021 (ClinicalTrials.gov identifier NCT 03003299). The debate between aortic VIV and reoperative AVR is framed by the trade-off between safety and durability. A transcatheter approach using aortic VIV has demonstrated low 30-day mortality and considerably lower perioperative morbidity compared with reoperative AVR.14Sedeek A.F. Greason K.L. Sandhu G.S. Dearani J.A. Holmes Jr., D.R. Schaff H.V. Transcatheter valve-in-valve vs surgical replacement of failing stented aortic biological valves.Ann Thorac Surg. 2019; 108: 424-430Google Scholar,16Tam D.Y. Dharma C. Rocha R.V. Ouzounian M. Wijeysundera H.C. Austin P.C. et al.Transcatheter ViV versus redo surgical AVR for the management of failed biological prosthesis: early and late outcomes in a propensity-matched cohort.JACC Cardiovasc Interv. 2020; 13: 765-774Google Scholar The majority of patients with failing bioprosthetic valves are older and THV durability might not be a compelling issue.14Sedeek A.F. Greason K.L. Sandhu G.S. Dearani J.A. Holmes Jr., D.R. Schaff H.V. Transcatheter valve-in-valve vs surgical replacement of failing stented aortic biological valves.Ann Thorac Surg. 2019; 108: 424-430Google Scholar Further investigation in younger patients is necessary before expanding indications for aortic VIV, but more therapeutic options are needed for the growing number of patients who are currently receiving bioprosthetic valves and face the challenge of BVF in the future.