Transcatheter Aortic Valve-in-Valve Replacement for Degenerated Stentless Bioprosthetic Aortic Valves

• Published in: JACC. Cardiovascular interventions Vol. 12; no. 13; pp. 1217 - 1226
• Main Authors: Miller, Matthew, Snyder, Mandy, Horne, Benjamin D., Harkness, James R., Doty, John R., Miner, Edward C., Jones, Kent W., O’Neal, Kelly R., Reid, Bruce B., Caine, William T., Clayson, Stephen E., Lindley, Eric, Gardner, Blake, Connors, Rafe C., Bowles, B. Jason, Whisenant, Brian K.
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.07.2019
• Subjects: coronary obstruction; Freestyle; stentless heart valve; LM; SBAV; ViV; THV; VTC; KCCQ; STJ; LV; IQR; coronary obstruction; TAVR; stentless heart valve; CT; RCA; Freestyle; STS; STS-PROM; MI
• ISSN: 1936-8798; 1876-7605
• DOI: 10.1016/j.jcin.2019.05.022

The purpose of this study was to evaluate the safety and efficacy of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) for stentless bioprosthetic aortic valves (SBAVs) and to identify predictors of adverse events. ViV TAVR in SBAVs is associated with unique technical challenges and risks. Clinical records and computer tomographic scans were retrospectively reviewed for procedural complications, predictors of coronary obstruction, mortality, and echocardiographic results. Among 66 SBAV patients undergoing ViV TAVR, mortality was 2 of 66 patients (3.0%) at 30 days and 5 of 52 patients (9.6%) at 1 year. At 1 year, left ventricular end-systolic dimension was decreased versus baseline (median [interquartile range (IQR)]: 3.0 [2.6 to 3.6] cm vs. 3.7 [3.2 to 4.4] cm; p < 0.001). Coronary occlusion in 6 of 66 procedures (9.1%) resulted in myocardial infarction in 2 of 66 procedures (3.0%). Predictors of coronary occlusion included subcoronary implant technique compared with full root replacement (6 of 31, 19.4% vs. 0 of 28, 0%; p = 0.01), short simulated radial valve-to-coronary distance (median [IQR]: 3.4 [0.0 to 4.6] mm vs. 4.6 [3.2 to 6.2] mm; p = 0.016), and low coronary height (7.8 [5.8 to 10.0] mm vs. 11.6 [8.7 to 13.9] mm; p = 0.003). Coronary arteries originated <10 mm above the valve leaflets in 34 of 97 unobstructed coronary arteries (35.1%). TAVR in SBAVs is frequently associated with high-risk coronary anatomy but can be performed with a low risk of death and myocardial infarction, resulting in favorable ventricular remodeling. A subcoronary surgical approach is associated with an increased risk of coronary obstruction. [Display omitted]