Valve-in-Valve Transcatheter Aortic Valve Replacement: From Pre-Procedural Planning to Procedural Scenarios and Possible Complications

Abstract

Over the last decades, bioprosthetic heart valves (BHV) have been increasingly implanted instead of mechanical valves in patients undergoing surgical aortic valve replacement (SAVR). Structural valve deterioration (SVD) is a common issue at follow-up and can justify the need for a reintervention. In the evolving landscape of interventional cardiology, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has emerged as a remarkable innovation to address the complex challenges of patients previously treated with SAVR and has rapidly gained prominence as a feasible technique especially in patients at high surgical risk. On the other hand, the expanding indications for TAVR in progressively younger patients with severe aortic stenosis pose the crucial question on the long-term durability of transcatheter heart valves (THVs), as patients might outlive the bioprosthetic valve. In this review, we provide an overview on the role of ViV TAVR for failed surgical and transcatheter BHVs, with a specific focus on current clinical evidence, pre-procedural planning, procedural techniques, and possible complications. The combination of integrated Heart Team discussion with interventional growth curve makes it possible to achieve best ViV TAVR results and avoid complications or put oneself ahead of time from them.

Keywords: TAVR; bioprosthetic heart valves; pre-procedural planning; structural valve deterioration.

Figure 1

Pre-procedural CT scan simulating a 26 Sapien 3 Ultra implantation showing good sealing of the THV prosthesis to the hinge points of the Perceval bioprosthesis at different heights (LVOT in panel (A) and SOV in panel (B)). CT: computed tomography; THV, transcatheter heart valve; LVOT, Left ventricular outflow tract; SOV, Sinus of Valsalva.

Figure 2

Risk of coronary artery obstruction evaluation at pre-procedural CT scan. Panel (A) Permissive height of LCA (18 mm). Panel (B) VTC of 5.9 mm simulating a 26 Sapien 3 Ultra with wide Sinus of Valsalva and redundant leaflet. CT, computed tomography; LCA; left coronary artery; VTC, valve to coronary ostia.

Figure 3

Pre-procedural CT of the aorta with a degenerated Evolut R 29. At SOV, evidence of an area of 4.8 cm² and a perimeter of 78 mm suitable for a Sapien 3 23. CT, computer tomography; SOV, Sinus of Valsalva.

Figure 4

Risk assessment of coronary obstruction in redo-TAVR. Panel (A) Determination of the risk plane which corresponds to the top of the neo-skirt (red line). Panel (B) Estimated VTC distance, respectively of 3.9 mm and 5.4 mm. Panel (C) Leaflets overhang aiming at node 6 implantation (as low as possible). VTC, valve to coronary ostia.

Figure 5

(A) buddy-balloon technique with VACS II 16 mm balloon inflation parallel to the Corevalve delivery to perform ViV in a Sorin Mitroflow 23 mm; (B) transfemoral TAVR with snare technique in a severe calcific native aortic valve stenosis VIV: valve-in-valve; TAVR: transcatheter aortic valve replacement.

Figure 6

(A) Bioprosthetic valve fracture with a True Balloon 20 balloon after valve-in-valve with Corevalve Evolut Pro + n.23 implantation in a Mitroflow 19 (LCA protection without final stent implantation) (B) IVUS shows patency of the VS with a minimum distance between aortic wall and prosthetic leaflet of 2.2 mm at STJ. LCA: left coronary artery; IVUS: intra-vascular ultrasound; STJ: sino-tubular junction distance.

Figure 7

Double Chimney Stenting Technique with 4.0 × 33 Everolimus eluting stent implantation at ostial RCA and 4.0 × 18 at proximal left main before Corevalve Evolut Pro + 23 mm valve-in-valve implantation in a Mitroflow 23.