From the Guidelines
Bioprosthetic aortic valve stenosis is primarily caused by calcification, fibrosis, or pannus formation on the valve leaflets, and its symptoms include shortness of breath, chest pain, and fatigue, which can be managed with valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) or surgical valve replacement, depending on symptom severity and patient characteristics. The condition typically develops 7-15 years after implantation of a biological heart valve in the aortic position, restricting blood flow from the heart to the body. Some key points to consider in the management of bioprosthetic aortic valve stenosis include:
- Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is a preferred treatment for symptomatic patients with severe stenosis, especially in older or higher-risk patients, as it avoids the risks of repeat open-heart surgery 1.
- Surgical valve replacement remains appropriate for younger, lower-risk patients.
- Medical therapy alone with diuretics, beta-blockers, and ACE inhibitors may help manage symptoms but doesn't address the underlying valve problem.
- Regular echocardiographic monitoring is essential for asymptomatic patients with mild to moderate stenosis, typically every 1-2 years.
- Anticoagulation with a vitamin K antagonist (VKA) is reasonable for patients with significant bioprosthetic valve stenosis attributable to suspected or documented valve thrombosis 1.
- A transcatheter ViV procedure is reasonable for severely symptomatic patients with bioprosthetic aortic valve stenosis and high or prohibitive surgical risk, when performed at a Comprehensive Valve Center 1. The management of bioprosthetic aortic valve stenosis should prioritize the patient's quality of life, morbidity, and mortality, and treatment decisions should be made on a case-by-case basis, taking into account the individual patient's characteristics and symptom severity.
From the Research
Causes of Bioprosthetic Aortic Valve Stenosis
- The causes of bioprosthetic aortic valve stenosis are not explicitly stated in the provided studies, but it can be inferred that the condition may be related to the durability of bioprosthetic valves, as many patients are expected to outlive their bioprosthetic valves 2, 3.
- Bioprosthetic valve dysfunction (BVD) can be classified as structural valve deterioration (SVD), non-structural valve dysfunction (NSVD), clinical valve thrombosis, or endocarditis 4.
- Severe SVD is defined as a transprosthetic gradient of 30 mmHg or more and an increase in transprosthetic gradient of 20 mmHg or more, or severe new intraprosthetic regurgitation 4.
Symptoms of Bioprosthetic Aortic Valve Stenosis
- The symptoms of bioprosthetic aortic valve stenosis are not explicitly stated in the provided studies, but it can be inferred that patients with severe aortic stenosis may experience symptoms such as chest pain, shortness of breath, and fatigue 2, 3.
- Patients with asymptomatic severe aortic stenosis may not exhibit any symptoms, but may still be at risk for adverse outcomes such as death, stroke, or unplanned hospitalization for cardiovascular causes 5.
- The risk of bioprosthetic valve failure (BVF) is a concern for patients with bioprosthetic aortic valves, and may be related to the development of symptoms such as heart failure or arrhythmias 4.
Treatment and Management
- Treatment options for bioprosthetic aortic valve stenosis include transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) 2, 3.
- The choice between TAVR and SAVR depends on various clinical and anatomical considerations, including the patient's surgical risk and the type of bioprosthetic valve used 3, 4.
- Planning for potential subsequent valve-in-valve interventions should begin at the time of the index procedure, taking into account factors such as coronary re-access and prosthesis-patient mismatch 2, 3.