Valve-in-valve treatment of dysfunctional aortic bioprostheses – single-centre experience

Introduction

Modern valvular bioprostheses show good durability, but there are several mechanisms that adversely affect their functionality. Besides dysfunction due to endocarditis (1–6%) or prosthetic valve thrombosis (up to 1%), structural valve degeneration (SVD) is the major concern [1]. Structural valve degeneration is defined as deterioration of the valve’s leaflets/structures resulting in thickening, calcification, tearing, or disruption of the prosthetic valve materials with or without hemodynamic dysfunction [2]. It may occur early after implantation, but typically starts approximately 8 years after valve replacement, and its prevalence rates rapidly increase 10 years after the procedure [3, 4]. The frequency of SVD is notably time-dependant: it ranges from 5–10% after 10 years, up to 36–51% after 20 years [5]. The growing number of patients requiring re-intervention due to bioprosthetic valve dysfunction and high periprocedural mortality associated with reoperation justifies the need for less invasive procedures [6]. Thus, transcatheter aortic valve-in-valve implantation (ViV-TAVI) is emerging as a promising treatment option [7, 8]. The transcatheter approach has been successfully attempted also in dysfunctional mitral bioprostheses, but the lack of dedicated mitral devices still limits its application mainly to patients with failed aortic bioprostheses [9]. In current guidelines, ViV-TAVI is considered as a therapeutic option for severely symptomatic patients with aortic bioprosthesis dysfunction and assessed by the Heart Team to be at high or prohibitive risk of reoperation, in whom improvement in hemodynamic is anticipated (Class IIa, LOF: B) [10].

Aim

This paper presents our single-center experience in ViV-TAVI for treatment of patients with dysfunctional bioprostheses after surgical aortic valve replacement (SAVR).

Material and methods

From a total of 311 transcatheter aortic valve implantations (TAVI) at our institution, we selected 8 cases treated due to SVD of a surgically implanted aortic bioprosthesis (either stented type or homograft). The baseline clinical characteristics of the ViV-TAVI group are shown in Table I. All patients were referred for ViV-TAVI by the local Heart Team due to high risk of reoperation.
Sizing of transcatheter heart valves (THV) was based on surgical valve label information, transoesophageal echocardiography (TEE) and/or computed tomography (CT) imaging supported with...


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