Abstract
Bioprosthetic surgical aortic valve failure requiring reintervention is a frequent clinical problem with event rates up to 20% at 10 years after surgery. Transcatheter aortic valve-in-valve implantation (ViV-TAVI) has become a valuable treatment option for these patients, although it requires careful procedural planning. We here describe and illustrate a stepwise approach to plan and perform ViV-TAVI and discuss preprocedural computerized tomography planning, transcatheter heart valve selection, and implantation techniques. Particular attention is paid to coronary artery protection and the possible need for bioprosthetic valve fracture since patients with small surgical aortic bioprostheses are at a risk of high residual gradients after ViV-TAVI. Considering updated clinical data on long-term outcomes following ViV-TAVI, this approach may become the default treatment strategy for patients with a failing surgical aortic bioprosthesis.
Highlights
Surgical implantation of a bioprosthetic aortic valve has been the treatment of choice for many patients with aortic valve stenosis (AS) or regurgitation
Bioprosthetic valve failure is defined as prosthetic dysfunction which leads to valve-related death, repeat intervention, or severe hemodynamic structural valve degeneration
ViV-TAVI has been upgraded from a class IIa (C) in the 2017 ESC guidelines to class IIa (B) recommendation in the 2021 ESC guidelines and should be considered based on anatomical characteristics and features of the surgical prosthesis and in patients at high surgical risk. ese recommendations are based on registry data and propensity-matched registry studies, showing better short- and long-term Journal of Interventional Cardiology outcomes with ViV-TAVI vs. redo surgery [6–8]
Summary
Surgical implantation of a bioprosthetic aortic valve (aortic valve replacement, AVR) has been the treatment of choice for many patients with aortic valve stenosis (AS) or regurgitation. In the recently updated ESC guidelines (2021), redo cardiac surgery is a class I, level of evidence C indication for symptomatic patients with bioprosthetic valve failure (after excluding thrombosis and endocarditis) and class IIa (C) indication for asymptomatic patients with low surgical risk [1]. Transcatheter aortic valve-invalve implantation (ViV-TAVI) has gained much attention in recent years because of the high procedural success rates of more than 90%. Journal of Interventional Cardiology outcomes with ViV-TAVI vs redo surgery [6–8] Considering these data and new insights, ViV-TAVI may become the preferred treatment for bioprosthetic valve failure, irrespective of the surgical risk category of the patient. We here systematically describe the approach to plan and perform a ViV-TAVI (Figure 1), carefully addressing the issues mentioned above, with particular attention to coronary artery protection strategies and bioprosthetic valve fracture (BVF) to avoid high residual gradients in case of small aortic bioprostheses
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