What are the recommendations for valve in valve Transcatheter Aortic Valve Implantation (TAVI)?

Valve-in-Valve TAVI Recommendations

Valve-in-valve Transcatheter Aortic Valve Implantation (ViV-TAVI) is recommended for patients with degenerated aortic bioprostheses who are at high risk for conventional redo surgery, with decision-making performed by a multidisciplinary heart team. 1

Patient Selection Criteria

The selection of candidates for ViV-TAVI should follow a structured approach:

• ViV-TAVI is indicated specifically for patients with calcified pure or predominant aortic stenosis in a previously implanted bioprosthetic valve 1
• Patient selection must involve multidisciplinary consultation between cardiologists, surgeons, imaging specialists, and anesthesiologists 1
• High surgical risk is defined by a logistic EuroSCORE of ≥15-20% or an STS mortality risk score of ≥10% 1
• Patient characteristics favoring ViV-TAVI over surgical reoperation include:
  • Prior cardiac surgery with grafts and/or adhesions 1
  • Previous chest radiation therapy 1
  • Porcelain aorta 1
  • Liver cirrhosis 1
  • Pulmonary hypertension 1
  • Right ventricular failure 1
  • Marked patient frailty 1

Contraindications

ViV-TAVI should not be performed in patients with:

• Life expectancy less than 1 year 1
• Unlikely improvement in quality of life due to comorbidities 1
• Severe primary disease of other valves that can only be treated surgically 1
• Thrombus in the left ventricle 1
• Active endocarditis 1
• Elevated risk of coronary ostium obstruction 1
• Inadequate vascular access for the chosen approach 1

Procedural Considerations and Challenges

ViV-TAVI presents specific challenges compared to primary TAVI:

• Higher rates of malposition due to lack of anatomic markers in stentless valves 2
• Increased risk of prosthesis-patient mismatch 3, 4
• Higher potential for coronary obstruction 5, 3
• Optimal procedural planning is crucial to minimize complications 5

Outcomes

The evidence on ViV-TAVI outcomes shows:

• High procedural success rates of approximately 93.8% 1
• Low 30-day mortality rates (0-6.3% for transfemoral approach) 1, 2
• One-year mortality of approximately 14.3% in high-risk patients 2
• Potential for device migration (reported in about 14% of cases with stentless valves) 2
• Need for permanent pacemaker implantation in 14-24% of cases, which is lower than with redo surgery 2, 4

Hemodynamic Outcomes

• ViV-TAVI generally results in good short and mid-term hemodynamic outcomes up to 2 years 1
• However, surgical redo AVR offers superior echocardiographic outcomes compared to ViV-TAVI:
  • Lower incidence of patient-prosthesis mismatch 4
  • Fewer paravalvular leaks 4
  • Lower mean postoperative aortic valve gradients 4

Decision Algorithm

1. Confirm the severity of bioprosthetic valve degeneration through echocardiography 1
2. Evaluate symptoms and their attribution to valve dysfunction 1
3. Assess surgical risk using validated scores (EuroSCORE, STS) 1
4. Evaluate life expectancy (must be >1 year) and potential for quality of life improvement 1
5. Assess feasibility and exclude contraindications for ViV-TAVI 1
6. For patients at low surgical risk, conventional redo surgery should remain the standard of care due to superior hemodynamic outcomes 4
7. For high-risk or inoperable patients, ViV-TAVI offers a less invasive alternative with acceptable mortality and morbidity 4

Imaging Requirements

• Comprehensive echocardiographic assessment is essential for evaluating valve degeneration 1
• Coronary angiography should be performed to assess coronary anatomy 1
• Accurate measurement of the aortic annulus is critical to minimize paravalvular leakage and avoid prosthesis migration 1
• Multiple imaging modalities (angiography, MSCT, MRI) should be used to evaluate vascular access routes 1

Potential Complications to Monitor

• Vascular complications (10-15% with transfemoral approach) 1
• Stroke (3-9%) 1
• Atrioventricular block requiring pacemaker (4-8%, up to 24% with self-expandable devices) 1
• Paravalvular leaks 1
• Device migration or embolization 2