Aortic valve-in-valve TAVR

Indications

Although there are no randomized clinical trials specifically addressing this treatment and the long-term durability of this treatment remains to be determined, the American Heart Association/American College of Cardiologists (AHA/ACC) guidelines for the management of patients with valvular heart disease give it a class IIa indication (level of evidence B) based on nonrandomized data, including registries and case series. Data from two large registries (Valve-in-Valve International Data and PARTNER II valve-in-valve registry) show that the most common indication for the procedure was valve stenosis in 30% to 50% of patients followed by pure valve regurgitation in 20% to 30%, and combined valve failure in the remaining patients. Reported 30-day mortality is up to 8%, stroke rate is up to 3%, and the 1-year survival rate is similar in both registries at 83% to 88%, respectively. ^,

AHA recommendations

Contraindications

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  Active endocarditis

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  Native prosthesis too small or too large for VIV transcatheter aortic valve replacement (TAVR)

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  Patient with poor life expectancy/comorbidities that would preclude likely benefit from VIV TAVR procedure

Specific considerations for valve-in-valve TAVR

When approaching transcatheter aortic VIV implantation, all the concepts that were described earlier in this book hold. This includes the building blocks of structural interventions, TAVR patient selection, and procedural planning. However, when planning an aortic VIV procedure, two major pitfalls that are unique for this procedure must be considered. First, therapy of small surgical valves should be approached with caution, as patient prosthesis mismatch (PPM) and significant residual gradients remain a major challenge, with 28% of patients having a residual aortic gradient of 20 mmHg or more. Second, when the indication for the procedure is valvular regurgitation, every effort should be taken to rule out aortic paravalvular leak because VIV implantation is not expected to improve hemodynamics in this case.

In addition to careful patient selection and procedural planning, the VIV procedure itself has particular operator-associated aspects that are different compared with standard TAVR. On the one hand, the surgical heart valve provides a perfect circular annulus to allow even expansion of the transcatheter valve. It is also a suitable anchor for fixation and can partially protect from complications such as annular rupture or complete atrioventricular (AV) block. On the other hand, operators must be aware of the critical importance of precise valve positioning and the risk of coronary obstruction.

Procedural planning