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Review
. 2024 Aug 12;13(16):4723.
doi: 10.3390/jcm13164723.

Aortic Valve-in-Valve Procedures: Challenges and Future Directions

Davide Cao  1   2 , Stefano Albani  1   3 , Emmanuel Gall  1   4   5   6 , Thomas Hovasse  1 , Thierry Unterseeh  1 , Patrick Seknadji  1 , Stéphane Champagne  1 , Philippe Garot  1 , Neila Sayah  1 , Mariama Akodad  1
Affiliations
Review

Aortic Valve-in-Valve Procedures: Challenges and Future Directions

Davide Cao et al. J Clin Med. .

Abstract

Aortic valve-in-valve (ViV) procedures are increasingly performed for the treatment of surgical bioprosthetic valve failure in patients at intermediate to high surgical risk. Although ViV procedures offer indisputable benefits in terms of procedural time, in-hospital length of stay, and avoidance of surgical complications, they also present unique challenges. Growing awareness of the technical difficulties and potential threats associated with ViV procedures mandates careful preprocedural planning. This review article offers an overview of the current state-of-the-art ViV procedures, with focus on patient and device selection, procedural planning, potential complications, and long-term outcomes. Finally, it discusses current research efforts and future directions aimed at improving ViV procedural success and patient outcomes.

Keywords: TAVR; coronary obstruction; valve-in-valve.

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Conflict of interest statement

Thomas Hovasse is a proctor for Medtronic. Philippe Garot reports receiving consultant/advisory honoraria from Abbott, Biosensors, Boston Scientific, Cordis, Edwards Lifesciences, General Electric Healthcare, and Terumo; serves as medical co-Director at the Cardiovascular European Research Center (CERC); he is shareholder of CERC, Electroducer and Basecamp vascular companies. Mariama Akodad is consultant for Edwards Lifesciences, Medtronic and Abbott.

Figures

Figure 1
Figure 1
Preprocedural ViV planning; wide arrow indicates both RCA and LCA coronaries ostium; orange circle indicates virtual Evolut Pro + 23 THV; white line indicates upper limit of anticipated neoskirt; red line indicates virtual THV to coronary ostial distance; CE: Carpentier Edwards; ID: internal diameter; LCA: left coronary artery; RCA: right coronary artery.
Figure 2
Figure 2
Challenges in aortic ViV-TAVI according to failed SHV; BVF: bioprosthetic valve fracture; SHV: surgical heart valve; THV: transcatheter heart valve; ViV: valve-in-valve.
Figure 3
Figure 3
Proposed algorithm for coronary risk obstruction assessment. Especially if bioprosthetic with externally mounted leaflets, † coronary protection strategies are as follows. Heterotopic snorkel stenting technique: wiring coronary artery and park an undeployed stent to be implanted after THV deployment if coronary flow is impaired. Orthotopic snorkel stenting technique: re-wiring after THV release to have a more physiologic stent implantation through prosthesis valve frame structure. BASILICA: “Bioprosthetic scallop intentional laceration to prevent iatrogenic coronary artery obstruction”, intentional laceration of surgical valve leaflets with electrified guidewire to create communication between sinus and neo-sinus. SAVR: surgical aortic valve replacement; SOV: sinuses of Valsalva; TAVI: transcatheter aortic valve implantation; ViV: valve-in-valve; VTC: virtual transcatheter heart valve to coronary distance; VTA: valve-to-aorta distance, STJ: sinotubular junction. * Especially if bioprosthetic with externally mounted leaflets.
Figure 4
Figure 4
Example of TAV-in-SAV at high risk of coronary obstruction. (A) Cannulation of both LCA and RCA using double-radial 6Fr approach. (B) Placement of guide extension catheter in RCA before deployment of Evolut Pro+ 23 THV in degenerated CE Magna 3000 21. (C) Final deployment of Evolut PRO+ 23 THV. (D) Undeployed drug-eluting stent positioned in RCA before post-dilatation. (E) Post-dilatation using non-compliant balloon. (F) Angiography showing good perfusion of both LCA and left sinus. (G) Aortogram showing impaired perfusion of RCA and right sinus while LCA is perfused. (H) Pull back and deployment of stent with its proximal portion positioned above neoskirt using chimney technique. (I) Final angiography showing good RCA perfusion. SHV: surgical heart valve; THV: transcatheter heart valve; ViV: Valve-in-Valve.
Figure 5
Figure 5
Example of HALT after aortic ViV. Wide arrow indicates hypoattenuating leaflet thickening (HALT). (A–D) Hypodensity corresponding to partial thrombosis of sinuses of Valsalva. (E,F) HALT of right and non-coronary THV leaflets.
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