Is TAVR (Transcatheter Aortic Valve Replacement) in TAVR a viable treatment option for severe aortic regurgitation?

TAVR-in-TAVR for Severe Aortic Regurgitation

For patients with severe aortic regurgitation after TAVR, valve-in-valve TAVR is an acceptable treatment option when surgical AVR carries prohibitive or high risk, though surgical AVR remains preferred if the patient is an acceptable surgical candidate. 1

Treatment Algorithm for Severe AR After TAVR

First-Line Approach: Surgical AVR

• Surgical aortic valve replacement should be considered first if the patient is a surgical candidate with acceptable surgical risk, as this provides the most definitive treatment for severe AR after TAVR 1
• The ACCF/AATS/SCAI/STS consensus explicitly states that treatment of severe AR after TAVR follows the same principles as native valve AR per ACCF/AHA valvular heart disease guidelines 1

Alternative Approach: TAVR-in-TAVR (Valve-in-Valve)

• Placement of a second TAVR within the leaking prosthesis ("valve-in-valve") is explicitly recognized as an alternative option when surgical AVR is not feasible 1
• This approach is particularly relevant for patients with acute severe AR or chronic severe AR with heart failure symptoms who cannot undergo surgery 1

Clinical Context and Timing

Acute vs. Chronic Presentation

• With acute severe AR or chronic severe AR with symptoms of heart failure, intervention is warranted rather than conservative management 1
• Post-TAVR AR is typically paravalvular and most commonly mild or mild-to-moderate in severity 1
• Moderate or severe AR occurs in approximately 12% of patients at 30 days and 7% at 1-year follow-up after TAVR 1

Prognostic Implications

• Moderate or severe AR after TAVR significantly increases mortality at both 30 days (odds ratio: 2.95) and 1 year (hazard ratio: 2.27), making intervention critical 2
• Post-procedural regurgitation is clearly associated with adverse outcomes, though no cases of hemolysis have been reported with TAVR despite paravalvular AR 1

Important Distinctions: Native AR vs. Post-TAVR AR

Critical Caveat

• TAVR is categorically excluded for treating native severe aortic regurgitation without significant calcification, as devices were designed exclusively for calcified, stenotic valves where calcification provides structural anchoring 3
• The question of TAVR-in-TAVR for post-procedural AR is fundamentally different from using TAVR for native AR, as the existing TAVR prosthesis provides the structural framework for anchoring a second valve 1

Decision-Making Framework

When to Choose TAVR-in-TAVR Over Surgery

• Prohibitive surgical risk (predicted risk of death or major morbidity >50% at 30 days) 1
• Disease affecting ≥3 major organ systems not likely to improve postoperatively 1
• Anatomic factors precluding surgery: heavily calcified (porcelain) aorta, prior radiation, arterial bypass graft adherent to chest wall 1
• Patient expected survival >1 year after intervention 1

When Surgery Remains Preferred

• Acceptable surgical risk patients should undergo surgical AVR as the gold standard 1
• Younger patients where long-term durability is paramount, as transcatheter valve durability beyond 3-4 years remains uncertain 1

Procedural Considerations

Technical Factors

• Valve-in-valve procedures inside small surgical bioprostheses (≤21 mm) carry increased mortality risk due to higher residual transvalvular gradients 1
• Higher (more aortic) valve positioning has been associated with lower residual gradients and potentially improved survival 1
• The existing TAVR prosthesis provides structural support that native AR lacks, making valve-in-valve technically feasible 1

Post-Procedural Management

• Standard antithrombotic therapy: clopidogrel 75 mg daily for 3-6 months plus aspirin 75-100 mg daily lifelong for patients without anticoagulation indications 4
• Echocardiography monitoring: before discharge for new baseline, at 30 days, then annually to monitor for complications 4
• Avoid multiple anticoagulant therapies in elderly patients with high bleeding risk 1

Common Pitfalls to Avoid

• Do not confuse TAVR-in-TAVR for post-procedural AR with TAVR for native AR – the former is guideline-supported while the latter is explicitly excluded 3
• Do not delay intervention in symptomatic severe AR after TAVR, as mortality risk increases significantly 2
• Do not assume all post-TAVR AR requires intervention – mild or mild-to-moderate AR requires only medical therapy for hypertension and periodic echocardiography monitoring 1
• Do not proceed with valve-in-valve without Heart Team evaluation involving interventional cardiology, cardiac surgery, imaging specialists, and heart failure specialists 3