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TAVR for Degenerated Stentless Bioprosthetic Valves
Study Questions:
What is the safety and efficacy of valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) for stentless bioprosthetic aortic valves (SBAVs) and predictors of adverse events?
Methods:
The Intermountain Healthcare database was queried to retrospectively identify and analyze consecutive patients with a history of stentless ViV TAVR performed at three Intermountain Healthcare hospitals between August 2013 and January 2019. Sixty-six patients with failed stentless bioprosthetic valves underwent ViV TAVR. The investigators retrospectively reviewed clinical records and computed tomographic scans of these patients for procedural complications, predictors of coronary obstruction, mortality, and echocardiographic results. Rank-based testing was performed with continuous variables using the Mann-Whitney-Wilcoxon test for comparison between groups, and tests of paired data used the Wilcoxon signed rank test.
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 [2.6-3.6] cm vs. 3.7 [3.2-4.4] cm; p < 0.001). Coronary occlusion in 6 of 66 procedures (9.1%) resulted in myocardial infarction (MI) 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 [0.0-4.6] mm vs. 4.6 [3.2-6.2] mm; p = 0.016), and low coronary height (7.8 [5.8-10.0] mm vs. 11.6 [8.7-13.9] mm; p = 0.003). Coronary arteries originated <10 mm above the valve leaflets in 34 of 97 unobstructed coronary arteries (35.1%).
Conclusions:
The authors concluded that TAVR in SBAVs is frequently associated with high-risk coronary anatomy, but can be performed with a low risk of death and MI, resulting in favorable ventricular remodeling.
Perspective:
This study reports that while failed stentless bioprosthetic valves are frequently associated with high-risk coronary anatomy and present unique technical challenges, it appears that TAVR can be performed with a low risk of complications including death, stroke, and MI, resulting in improved hemodynamics, quality of life, and favorable LV remodeling. However, clinicians should note that a subcoronary surgical approach, a short radial VTC distance, and low coronary height are factors associated with increased risk of coronary obstruction. Since the current study is observational and retrospective, these findings should be confirmed in future prospective studies.
Keywords: Cardiac Surgical Procedures, Coronary Occlusion, Echocardiography, Heart Valve Diseases, Heart Valve Prosthesis, Hemodynamics, Myocardial Infarction, Quality of Life, Secondary Prevention, Stroke, Transcatheter Aortic Valve Replacement, Ventricular Remodeling, Tomography, X-Ray Computed
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