Trans-Catheter Valve-in-Valve Implantation for the Treatment of Aortic Bioprosthetic Valve Failure

Abstract

Aortic valve-in-valve (ViV) procedure is a valid treatment option for patients affected by bioprosthetic heart valve (BHV) degeneration. However, ViV implantation is technically more challenging compared to native trans-catheter aortic valve replacement (TAVR). A deep knowledge of the mechanism and features of the failed BHV is pivotal to plan an adequate procedure. Multimodal imaging is fundamental in the diagnostic and pre-procedural phases. The main challenges associated with ViV TAVR consist of a higher risk of coronary obstruction, severe post-procedural patient-prosthesis mismatch, and a difficult coronary re-access. In this review, we describe the principles of ViV TAVR.

Keywords: TAVR; bioprosthetic valve failure; structural valve degeneration; valve-in-valve.

Figure 1

Available portfolio of THVs and surgical BHVs regrouped according to their main features: in purple, devices with self-expanding design; in red, devices with balloon-expandable design; in green, devices made by porcine tissue; in blue, devices made by bovine pericardial tissue; in orange, devices made by equine pericardial tissue. BHV: bioprosthetic heart valve; THV: trans-catheter heart valve. *CE mark for valve-in-valve use.

Figure 2

Practical diagnostic and therapeutic algorithm in case of BHV failure suspicion. BHV: bioprosthetic heart valve; BVF: balloon valve fracturing; MSCT: multi-slice computed tomography; PPM: patient-prosthesis mismatch; PVL: paravalvular leak; SVD: structural valve deterioration; TAVR: trans-catheter aortic valve replacement; ViV: valve-in-valve.

Figure 3

Multimodal imaging approach to assess the feasibility of ViV TAVR for PVL correction. A patient, with previous Evolut R 34 mm (Medtronic) implantation, presented with severe paravalvular leak (PVL) at transthoracic (A) and transesophageal (B) echocardiography, due to low device implantation. Multi-slice computed tomography (MSCT) confirmed the PVL mechanism, showing incomplete native annulus sealing by the narrow part of the trans-catheter (THV) waist (in (C) blue arrows indicate the two gaps); moreover, also the internal THV skirt was too low and unable to properly work (D.1,D.2). MSCT allowed a simulation of ViV TAVR using a balloon-expandable Sapien 3 29 mm (Edwards, blue circle in (E)), able to stretch the self-expanding device frame in order to correctly seal the native annulus. Angiographic evidence of pre-ViV TAVR PVL with confirmation of previous low THV implantation (F.1) and final result (F.2). Post-procedural MSCT showed a proper PVL mechanism correction (G.1,G.2), with only mild residual PVL at pre-discharge echocardiographic assessment (H). TAVR: trans-catheter aortic valve replacement; ViV: valve-in-valve.

Figure 4

Prediction of coronary artery obstruction. A 60-year-old lady presented with Carpentier-Edwards Perimount BHV degeneration. The BHV frame extends above the coronary ostia, but below the sinotubular junction (A.1,A.2), showing RCA distance from the annulus of 3.9 mm). This situation is potentially at increased coronary obstruction risk. In this case, the following step is to calculate the VTC distance, intended as the distance between the prosthetic frame and coronary ostia: for the LCA the VTC is 5.4 mm (B.1) whereas a shorter VTC is depicted for the RCA (B.2). Considering a cut-off value of 4 mm, the patient is judged at negligible risk of LCA occlusion during ViV TAVR but at increased risk for RCA occlusion. For this reason, prophylactic RCA wiring and stenting are performed during ViV TAVR (C).

Figure 5

Risk of coronary artery obstruction during ViV TAVR according to VIVID classification. BASILICA: bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction; CO: coronary obstruction; STJ: sinotubular junction; TAVR: trans-catheter aortic valve replacement; ViV: valve-in-valve; VTC: virtual-to-coronary distance; VTSTJ: virtual-to-sinotubular junction distance.