Valve-in-valve transcatheter aortic valve implantation for degenerated bioprosthetic heart valves.

We sought to analyze outcomes of patients with degenerated surgically implanted bioprosthetic heart valves undergoing valve-in-valve (viv) transcatheter aortic valve implantation (TAVI). Redo cardiac surgery for degenerated bioprosthetic heart valves is associated with increased risks, particular in elderly patients with comorbidities. For these patients, TAVI may be an attractive, less invasive treatment option. Data from 47 patients age 64 to 97 years (logistic euroSCORE: 35.0 ± 18.5%) undergoing transfemoral (n = 25) or transapical (n = 22) viv-TAVI for failed bioprosthetic aortic valves 113 ± 65 months after initial surgery at 9 clinical sites in Germany and Switzerland were analyzed. Valve-in-valve TAVI was technically successful in all patients, with 2 patients requiring bailout implantation of a second TAVI prosthesis for severe regurgitation during the procedure. There was 1 procedural death as the result of low-output failure. Valvular function after viv-TAVI was excellent with respect to valve competence, but increased transvalvular gradients ≥20 mm Hg were noted in 44% of patients. Vascular access complications occurred in 6 (13%) patients, and 5 (11%) patients required new pacemaker implantation after viv-TAVI. Renal failure requiring dialysis occurred in 4 (9%) patients. Mortality at 30 days was 17% (1 procedural and 7 post-procedural deaths), with 3 of 8 fatalities the result of non-valve-related septic complications. Valve-in-valve TAVI can be performed with high technical success rates, acceptable post-procedural valvular function, and excellent functional improvement. However, in these predominantly elderly high-risk patients with multiple comorbidities, viv-TAVI was associated with 17% mortality, often because of septic complications arising in the post-operative phase.

Eggebrecht H ，Schäfer U ，Treede H ，Boekstegers P ，Babin-Ebell J ，Ferrari M ，Möllmann H ，Baumgartner H ，Carrel T ，Kahlert P ，Lange P ，Walther T ，Erbel R ，Mehta RH ，Thielmann M ... -  《-》

What is the best approach in a patient with a failed aortic bioprosthetic valve: transcatheter aortic valve replacement or redo aortic valve replacement?

A best evidence topic in cardiac surgery was written according to a structured protocol. The question addressed was whether transcatheter aortic valve-in-valve replacement (viv-TAVR) or redo aortic valve replacement (rAVR) is the best strategy in a patient with a degenerative bioprosthetic aortic valve. Altogether, 162 papers were found using the reported search, of which 12 represented the best evidence to answer the question. The authors, journal, date, country of publication, patient group, study type, outcomes and results of papers are tabulated. The results of the studies provided interesting results. All the studies are retrospective. Four papers reported the results of redo aortic valve replacement in patients with failed aortic bioprosthetic valve, six papers demonstrated their results with transcatheter aortic valve-in-valve replacement for the same indication and two papers reported their propensity-matched analysis of outcomes between viv-TAVR and rAVR in patients with previous cardiac surgery. Thirty-day mortality for rAVR was 2.3-15.5% and 0-17% for viv-TAVR. For rAVR, survival rate at 30 days was 83.6%, 76.1% at 1 year, 70.8% at 3 years, at 51.3-66% at 5 years, 61% at 8 years and 61.5% at 10 years. For viv-TAVR, the overall Kaplan-Meier survival rate at 1 year was 83.2%. After viv-TAVR at 1 year, 86.2% of surviving patients were at New York Heart Association (NYHA) class I/II. The complications after rAVR were stroke (4.6-5.8%), reoperation for bleeding (6.9-9.7%), low-cardiac output syndrome (9.9%) whereas complications after viv-TAVR at 30 days were major stroke (1.7%), aortic regurgitation of at least moderate degree (25%), new permanent pacemaker implantation rate (0-11%), ostial coronary obstruction (2%), need for implantation of a second device (5.7%) and major vascular complications (9.2%). It is noteworthy to mention that there is a valve-in-valve application that provides information to surgeons for choosing the correct size of the TAVR valve. Transcatheter aortic valve-in-valve procedures are clinically effective, at least in the short term, and could be an acceptable approach in selected high-risk patients with degenerative bioprosthetic valves. Redo AVR achieves acceptable medium and long-term results. Both techniques could be seen as complementary approaches for high-risk patients.

Tourmousoglou C ，Rao V ，Lalos S ，Dougenis D ... -  《-》

Valve-in-valve implantation of Medtronic CoreValve prosthesis in patients with failing bioprosthetic aortic valves.

Linke A ，Woitek F ，Merx MW ，Schiefer C ，Möbius-Winkler S ，Holzhey D ，Rastan A ，Ender J ，Walther T ，Kelm M ，Mohr FW ，Schuler G ... -  《-》

Use of transcatheter heart valves for a valve-in-valve implantation in patients with degenerated aortic bioprosthesis: technical considerations and results.

Transcatheter aortic valve implantation has been used to treat high-risk patients with bioprosthetic valve degeneration (valve-in-valve). We report our experience with transcatheter aortic valve implantation in the treatment of degenerated biologic aortic valve prostheses and discuss factors that can influence the outcome. From February 2009 to October 2011, 278 patients underwent transcatheter aortic valve implantation, of whom 23 underwent a valve-in-valve procedure with the Edwards Sapien valve to treat a failing bioprostheses in the aortic position. Eight of these valves were stentless bioprostheses. Thirteen patients had valve failure resulting predominantly from stenosis, and the remaining resulting from regurgitation. Mean age was 76.9 ± 14.4 years. The mean logistic EuroSCORE was 31.8% ± 20.3% and the Society of Thoracic Surgeons score was 7.6% ± 5.4%. All patients were New York Heart Association class III or IV. The majority of the operations (21/23) were performed via the transapical route. Procedural success was 100%, although 1 patient with a degenerated homograft needed immediate placement of a second valve because of low placement of the first. The reduction in the mean gradient was 31.2 ± 17.06 mm Hg to 9.13 ± 4.9 mm Hg. In those patients with predominant aortic regurgitation (9/23), reduction in aortic regurgitation was achieved in all. The median length of stay was 11.7 days (range, 3-44 days). In-hospital and/or 30-day mortality was 0%. Valve-in-valve is a safe and feasible alternative to treat high-risk patients with failing aortic bioprostheses. The early results are excellent, with improvement seen in hemodynamics.

Bapat V ，Attia R ，Redwood S ，Hancock J ，Wilson K ，Young C ，Thomas M ... -  《-》

Transcatheter Aortic and Mitral Valve-in-Valve Implantation for Failed Surgical Bioprosthetic Valves: An 8-Year Single-Center Experience.

We report our 8-year experience in transcatheter aortic and mitral valve-in-valve (VinV) implantation. Feasibility and good early outcomes associated with transcatheter aortic and mitral VinV implantation into failed surgical bioprostheses have been confirmed, but the mid-term and long-term outcomes of transcatheter aortic and mitral VinV is unknown. A total of 73 patients with aortic (n = 42) and mitral (n = 31) bioprosthetic valve dysfunction underwent transcatheter VinV implantation between April 2007 and December 2013. Edwards balloon-expandable transcatheter valves (Edwards Lifesciences Inc., Irvine, California) were used. Median follow-up was 2.52 years with a maximum of 8 years. Seventy-two patients (mean age 79.7 ± 9.4 years, 32 women) underwent successful VinV implantation (success rate 98.6%). At 30 days, all-cause mortality was 1.4%, disabling stroke 1.4%, life-threatening bleeding 4.1%, acute kidney injury requiring hemodialysis 2.7%, and coronary artery obstruction requiring intervention 1.4%. No patient had greater than mild paravalvular leak. Estimated survival rates were 88.9%, 79.5%, 69.8%, 61.9%, and 40.5% at 1, 2, 3, 4, and 5 years, respectively. The small surgical valve size (19 and 21 mm) was an independent risk factor for reduced survival in aortic VinV patients. At 2-year follow-up, 82.8% of aortic and 100% of mitral VinV patients were in New York Heart Association functional class I or II. Transcatheter VinV for failed surgical bioprostheses can be performed safely with a high success rate and minimal early mortality and morbidity. Transcatheter VinV provides encouraging mid-term clinical outcomes in this high-risk elderly cohort of patients. Transcatheter VinV is an acceptable alternative therapy for failed aortic or mitral bioprostheses in selected high-risk patients.

Ye J ，Cheung A ，Yamashita M ，Wood D ，Peng D ，Gao M ，Thompson CR ，Munt B ，Moss RR ，Blanke P ，Leipsic J ，Dvir D ，Webb JG ... -  《-》