Transcatheter aortic valve implantation in degenerated surgical aortic valves

Abstract

Transcatheter aortic valve implantation (TAVI) within failed bioprosthetic surgical aortic valves (valve-in-valve TAVI) has become an established procedure, currently approved for patients deemed at high risk for repeat aortic valve intervention. Although less invasive than surgical reoperation, challenges of valve-in-valve treatment include higher rates of malposition, prosthesis-patient mismatch and coronary obstruction. Thus, optimal patient selection and preprocedural planning is of the utmost importance to minimise the risk of these complications. In this review article we provide a fully illustrated overview of the most significant periprocedural operative considerations for valve-in-valve TAVI.

Figure 1

Different mechanisms of aortic bioprosthesis valve dysfunction on transoesophageal echocardiography (TEE) exam. A) Three-dimensional TEE image (short-axis view) of a stented bioprosthesis, showing thickened and calcified leaflets (arrow) causing severe stenosis. B) Two-dimensional TEE image (long-axis view) of a stentless bioprosthesis, showing prolapse of the non-coronary cusp (arrow) leading to severe aortic regurgitation. C) Two-dimensional TEE image (short-axis view) of a stentless bioprosthesis, showing a thrombus (arrow) at the level of the non-coronary cusp. D) Two-dimensional TEE image of a stented bioprosthesis, showing endocarditis vegetations (arrows) at the ventricular side.

Figure 2

Examples of stented surgical aortic valves. A) 23 mm Mosaic™ porcine valve (Medtronic). B) 23 mm Magna 3000 pericardial valve (Edwards Lifesciences). C) 23 mm Mitroflow externally mounted pericardial valve (LivaNova PLC), where the manufacturer labelled size, stent and true internal diameters are different.

Figure 3

Effect of leaflet type and mounting on the stent and true internal diameter (ID) of stented surgical aortic valves. A) Porcine valves: true internal diameter (ID) is at least 2 mm less than the stent ID. B) Pericardial valves with leaflets sutured inside the stent frame: true ID is at least 1 mm less than the stent ID. C) Pericardial valves with leaflets sutured outside the stent frame: true ID is the same as the stent ID.

Figure 4

Proposed algorithm to determine aortic root anatomy and indication for BASILICA in ViV TAVI. * Either above, at, or up to 2 mm below the plane of the STJ. The threshold to define a narrow VTSTJ is unknown and is currently considered as <2.5-3.5 mm (<2.5 mm is a high-risk condition and 2.5-3.5 mm is an intermediate-risk condition). BASILICA: bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction; STJ: sinotubular junc-tion; TAVR: transcatheter aortic valve replace-ment; VTC: virtual transcatheter heart valve to coronary distance; VTSTJ: virtual transcatheter heart valve to sinotubular junction distance

Figure 5

Factors impacting coronary access after TAV-in-SAV in prostheses with a sub-coronary or supra-coronary risk plane. A) Factors impacting coronary access after TAV-in-SAV. B) Sub-coronary risk plane and supra-coronary risk plane. RP: risk plane; SAV: surgical aortic valve; TAV: transcatheter aortic valve; VTC: virtual transcatheter heart valve to coronary distance; VTSTJ: virtual transcatheter heart valve to sinotubular junction distance

Figure 6

Two cases of ViV TAVI. A) Valve-in-valve TAVI with a SAPIEN 3 valve (Edwards Lifesciences). The dotted circle identifies an open cell in the upper part of the stent frame. B) A case of ViV TAVI with a small VTSTJ in which the coronary artery could not be selectively engaged despite the implantation of a low-frame prosthesis with large cell size.

Figure 7

Impact on coronary access of misaligned high THV commissural posts. A) Commissure height of different transcatheter heart valves. B) Examples of neo-commissure alignment versus misalignment with the native coronary ostia.

Central illustration

Overview of patient selection, preprocedural evaluation and procedural aspects of valve-in-valve TAVI. BASILICA: bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction; BVF: balloon valve fracture; CEPD: cerebral embolic protection device; CT: computed tomography; ID: internal diameter; NSVD: non-structural valve deterioration; SVD: structural valve deterioration; ViV: valve-in-valve; VIVID: Valve-in-Valve International Data; VTC: virtual transcatheter heart valve to coronary distance; VTSTJ: virtual transcatheter heart valve to sinotubular junction distance