What is the optimal valve choice for a 71-year-old male with severe aortic regurgitation (AR) and degenerated bioprosthetic valve, considering a valve-in-valve transcatheter aortic valve replacement (ViV TAVR) with either a 23 mm S3UR or 26 mm Evolut Fx valve?

From the Guidelines

I strongly recommend using the 23 mm S3UR valve for this valve-in-valve TAVR procedure. This patient has a degenerated 25 mm Sorin Mitroflow bioprosthetic valve with severe eccentric aortic regurgitation, as evidenced by the TTE and TEE results, which show moderate to severe AR and a severely dilated left atrium 1. The S3UR valve would be preferable because it offers better expansion within the existing valve frame and typically provides superior hemodynamics in valve-in-valve procedures compared to the self-expanding Evolut Fx, as supported by the Valve-In-Valve International Data registry outcomes 1.

The patient's existing valve size (25 mm) makes the 23 mm S3UR an appropriate size match to avoid patient-prosthesis mismatch while ensuring adequate anchoring. The overall management plan is appropriate, including holding dapagliflozin to avoid dehydration, implementing heparin bridging while holding apixaban, and using IV diuretics to optimize volume status before the procedure, as recommended by the 2020 ACC/AHA guideline for the management of patients with valvular heart disease 1.

Given the patient's history of heart failure with preserved ejection fraction, coronary artery disease, and atrial fibrillation, close monitoring of fluid status and cardiac rhythm will be essential during the perioperative period. The patient's STS Risk Score Mortality of 1.77% and EuroScore II of 3.28% indicate a relatively high surgical risk, making the transcatheter ViV procedure a suitable alternative, as suggested by the guideline 1.

Key considerations for this procedure include:

• The patient's severe eccentric aortic regurgitation and degenerated bioprosthetic valve
• The need for careful sizing and selection of the valve to avoid patient-prosthesis mismatch
• The importance of close monitoring of fluid status and cardiac rhythm during the perioperative period
• The potential benefits of the S3UR valve in terms of hemodynamics and deployment predictability
• The overall management plan, including medication adjustments and perioperative care, as recommended by the guideline 1.

From the Research

Patient Profile

• The patient, Ramon Delacruz, is a 71-year-old male with a history of severe aortic regurgitation (AR) and multiple comorbidities, including heart failure with preserved ejection fraction (HFpEF), pulmonary hypertension (pHTN), and coronary artery disease (CAD).
• He has undergone previous surgical aortic valve replacement (SAVR) with a Sorin Mitroflow bio-AVR 25 mm in 2014 and has since developed degenerated bioprosthetic valve.
• The patient's current symptoms and hospital admissions suggest a need for valve replacement or repair.

Valve Replacement Options

• The plan is to perform a Valve-in-Valve (ViV) Transcatheter Aortic Valve Replacement (TAVR) with either a 23 mm S3UR or 26 mm Evolut Fx valve.
• According to a study published in 2024 2, self-expanding supraannular valves, such as the Evolut Fx, have been shown to be noninferior to balloon-expandable valves in terms of clinical outcomes and superior in terms of bioprosthetic-valve dysfunction in patients with small aortic annuli.
• However, the choice of valve size and type should be individualized based on the patient's anatomy and clinical characteristics.

Perioperative Management

• The patient is currently taking dapagliflozin, which has been shown to reduce the risk of heart failure admission in high-risk patients 3.
• However, the plan is to hold dapagliflozin, which may be reasonable given the patient's upcoming TAVR procedure and potential risks of hypotension and genital infection associated with SGLT2 inhibitors.
• The use of heparin and holding of apixaban is also planned, which is consistent with standard perioperative management for TAVR procedures.

Risk Assessment

• The patient's STS Risk Score Mortality is 1.77%, and EuroScore II is 3.28%, indicating a relatively low to moderate risk for surgical mortality.
• However, the patient's multiple comorbidities and history of previous cardiac surgery may increase the risk of perioperative complications.
• A study published in 2000 4 highlights the importance of identifying high-risk surgical patients and implementing strategies to reduce morbidity and mortality from organ dysfunction in surgical intensive care.