Redo-Transcatheter Aortic Valve Implantation Using the SAPIEN 3/Ultra Transcatheter Heart Valves-Expert Consensus on Procedural Planning and Techniques

[How to deal with elevated gradient following TAVR?]

Over the past two decades, transcatheter aortic valve implantation (TAVI) has become a safe and effective therapeutic option for symptomatic and severe aortic stenosis, regardless of the surgical risk spectrum. With the expansion of TAVI indications to low-risk and younger patients, it is crucial to ensure satisfactory and durable hemodynamic outcomes to guarantee transcatheter heart valve (THV) longevity. However, secondary THV dysfunction may occur, often manifested by an increased transvalvular gradient. According to VARC-3 criteria, these dysfunctions can be attributed to four main mechanisms: 1) structural valve deterioration; 2) non-structural valve dysfunction; 3) thrombosis; 4) and endocarditis. Each mechanism leads to specific abnormalities, requiring a systematic diagnostic approach and appropriate treatment. This article illustrates, through two clinical cases, the diagnosis and management of secondary transvalvular gradient elevation after TAVI.

A Guide to Transcatheter Aortic Valve Design and Systematic Planning for a Redo-TAV (TAV-in-TAV) Procedure

Transcatheter aortic valve replacement (TAVR) has become more common than surgical aortic valve replacement since 2016, with over 200,000 procedures globally each year. As patients increasingly outlive their TAVR devices, managing these cases is a growing concern. Treatment options include surgical removal of the old TAVR device (transcatheter aortic valve [TAV] explant) or implantation of a new transcatheter aortic valve (redo TAV). Redo TAV is complex because of the unique designs of TAV devices; compatibility issues; and the need for individualized planning based on factors such as implant depth, shape, and coronary artery relationships. This review serves as a comprehensive guide for redo TAV, detailing the design characteristics of TAV devices, device compatibility, standardized terminology, and a structured approach for computed tomography analysis. It aims to facilitate decision making, risk identification, and achieving optimal outcomes in redo TAV procedures.

Balloon-Expandable Valve for the Treatment of Self-Expanding Valve Failure: The Need for a Tailored Approach

An 82-year-old patient experienced symptomatic intra-prosthetic aortic regurgitation 5 years after self-expandable transcatheter heart valve (THV) implantation. Redo-transcatheter aortic valve replacement was initially considered at high risk of coronary obstruction. Using a systematic computed tomography-based approach planning a low implantation with a SAPIEN 3 Ultra THV, we effectively mitigated risks.

Use of SAFARI 2™ as workhorse wire for left-sided structural heart interventions

BACKGROUND

With the advances in percutaneous treatment technologies, the left atrial appendage occlusion (LAAO) and the transcatheter mitral valve repair using MitraClip (TMVR) are increasingly being performed today. The SAFARI 2™ guidewire is primarily used during transcatheter aortic valve implantation (TAVI), our group has also been using it during MitraClip and LAAO procedures. Our clinical study aimed to share our data on the safety and effectiveness for the use of the SAFARI 2™ guidewire during MitraClip or LAAO procedures.

METHODS

This study included a total of 1730 patients (948 patients of MitraClip and 782 of LAAO). It was designed as single arm, retrospective, and multicenter between July 2016 and August 2022. SAFARI 2™ guidewire was used exclusively during all the procedures.

RESULTS

A total of 1730 patients (male 55.8 %) were included in the study. There was no guidewire-related complications, stroke/transient ischemic attack, bleeding (minor/major/life-threatening), need for cardiac surgery, pneumonia, and vascular dissection/rupture in patients undergoing LAAO. There were 2 device-related pericardial effusions without tamponade. No stroke/transient ischemic attack, bleeding (minor/major/life-threatening), mortality, need for cardiac surgery, pneumonia, guidewire-related complication, pericardial effusion, vascular dissection/rupture, or clip embolization was observed in patients undergoing MitraClip.

CONCLUSIONS

By taking advantage of its pre-shaped structure, the SAFARI 2™ guidewire seems to offer a reliable and safe device delivery for both MitraClip and LAAO procedures as a regular work horse wire. Our results should be confirmed by larger randomized or prospective trials.

Effects of implantation height on the performance of a redo transcatheter aortic valve replacement using a balloon-expandable valve

Objective

The use of the transcatheter aortic valve in low-risk patients might lead to a second intervention due to the deterioration of the first 1. Understanding the implantation height is key to an effective redo transcatheter aortic valve replacement treatment.

Methods

The effects of implantation height on the performance of a balloon-expandable valve within a self-expandable valve were assessed using hemodynamic testing and particle image velocimetry. The hemodynamic performances, leaflet kinematics, and turbulent shear stresses were measured and compared.

Results

When a second balloon-expandable valve was positioned at varying heights relative to the first self-expandable valve, the leaflet motion of the first valve transitioned from free opening and closing to overhanging, and eventually to being entirely pinned to the stent, forming a neo-skirt. When the leaflets of the self-expandable valve could move freely, a decrease in regurgitation fraction was observed, but with an increased pressure gradient across the valve. Flow visualization indicated that the overhanging leaflets disrupted the flow, generating a higher level of turbulence.

Conclusions

This study suggests that the overhanging leaflets should be avoided, whereas the other 2 scenarios should be carefully evaluated based on an individual patient's anatomy and the cause of failure of the first valve.

Procedural and clinical outcomes of patients undergoing a TAVI in TAVI procedure: Rationale and design of the multicentre, prospective, observational ReTAVI registry

BACKGROUND

Transcatheter aortic valve implantation (TAVI) is increasingly being used in younger patients and those with lower peri-procedural risk, meaning more patients will live long enough to experience structural valve deterioration (SVD) of the bioprosthesis, indicating repeated TAVI. Experience of repeated TAVI-transcatheter heart valve (THV) implantation into an index THV is limited. This registry aims to assess the peri-procedural and short-term safety, efficacy and durability of repeated TAVI.

METHODS

The ReTAVI Prospective observational registry is an investigator-initiated, multicentre, international, prospective registry of patients undergoing repeated TAVI using balloon-expandable SAPIEN prosthesis to evaluate procedural and short-term safety, efficacy and durability as well as anatomical and procedural factors associated with optimal results. The registry will enrol at least 150 patients across 60 high-volume centres. Patients must be ≥18 years old, have had procedural success with their first TAVI, have index THV device failure, intend to undergo repeated TAVI and be considered suitable candidates by their local Heart Team. All patients will undergo a 30-day and 12-month follow-up. The estimated study completion is 2025.

CONCLUSIONS

The registry will collect pre-, peri-, postoperative and 12-months data on patients undergoing repeated TAVI procedures with THVs for failure of the index THV and determine VARC-3-defined efficacy and safety at 30 days and functional outcome at 12 months. The registry will expand existing data sets and identify patient characteristics/indicators related to complications and clinical benefits for patients with symptomatic severe calcific degenerative aortic stenosis.

Valve-in-valve transcatheter aortic valve implantation: The issues behind crossing a bioprosthesis

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) is rapidly arising as a safe and effective alternative to redo-surgery in the treatment of bioprostheses deterioration. While scientific community is currently focusing its attention on the most common limitations related to this procedure, such as the risk of coronary obstruction and patient-prosthesis mismatch, data regarding the first step of a ViV TAVI, the crossing of a degenerated bioprosthesis, are still lacking. The aim of this review is to analyze the available information about bioprosthesis crossing, to show the inherent challenges encountered by interventional cardiologists during valve crossing and to describe the current strategies to perform a correct crossing.

Clinical considerations and challenges in TAV-in-TAV procedures

Transcatheter aortic valve replacement (TAVR) has emerged as a viable treatment for aortic valve disease, including low-risk patients. However, as TAVR usage increases, concerns about long-term durability and the potential for addition interventions have arisen. Transcatheter aortic valve (TAV)-in-TAV procedures have shown promise in selected patients in numerous registries, offering a less morbid alternative to TAVR explantation. In this review, the authors aimed to comprehensively review the experience surrounding TAV-in-TAV, summarize available data, discuss pre-procedural planning, highlight associated challenges, emphasize the importance of coronary obstruction assessment and provide insights into the future of this technique.

Degenerated Transcatheter Aortic Valve Replacement: Investigation and Management Options

With the expansion of transcatheter aortic valve replacement (TAVR) to younger and lower-surgical-risk patients, many younger and less comorbid patients will be treated with TAVR and are expected to have a life expectancy that will exceed the durability of their transcatheter heart valve. Consequently, the number of patients requiring reintervention will undoubtedly increase in the near future. Redo-TAVR and TAVR explantation followed by surgical aortic valve replacement are the different therapeutic options in the event of bioprosthetic valve failure and the need for reintervention. Patients often anticipate being able to benefit from a redo-TAVR in the event of bioprosthetic valve failure after TAVR, despite the lack of long-term data and the risk of unfavourable anatomy. Our understanding of the feasibility of redo-TAVR is constantly improving thanks to bench test studies and growing worldwide experience. However, much remains unknown. In clinical practice, one of the heart team's objectives is to anticipate the need to reaccess the coronary arteries and implant a second or even a third valve when life expectancy may exceed the durability of the transcatheter heart valve. In this review, we address key definitions in the diagnosis of structural valve deterioration and bioprosthetic valve failure, as well as patient selection and procedural planning for redo-TAVR to reduce periprocedural risk, optimise hemodynamic performance, and maintain coronary access. We describe the bench testing and literature in the redo-TAVR and TAVR explantation fields.

Transcatheter Aortic Valve Implantation to Treat Degenerated Aortic, Mitral and Tricuspid Bioprosthesis

Transcatheter aortic valve implantation (TAVI) is now well established as the treatment of choice for patients with native aortic valve stenosis who are high or intermediate risk for surgical aortic valve replacement. Recent data has also supported the use of TAVI in patients at low surgical risk and also in anatomical subsets that were previously felt to be contra-indicated including bicuspid aortic valves and aortic regurgitation. With advancements and refinements in procedural techniques, the application of this technology has now been further expanded to include the management of degenerated bioprosthesis. After the demonstration of feasibility and safety in the management of degenerated aortic bioprosthetic valves, mitral and tricuspid bioprosthetic valve treatment is now also well-established and provides an attractive alternative to performing redo surgery. In this review, we appraise the latest clinical evidence and highlight procedural considerations when utilising TAVI technology in the management of degenerated aortic, mitral or tricuspid prosthesis.

Valve-in-Valve Transcatheter Aortic Valve Replacement: From Pre-Procedural Planning to Procedural Scenarios and Possible Complications

Over the last decades, bioprosthetic heart valves (BHV) have been increasingly implanted instead of mechanical valves in patients undergoing surgical aortic valve replacement (SAVR). Structural valve deterioration (SVD) is a common issue at follow-up and can justify the need for a reintervention. In the evolving landscape of interventional cardiology, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has emerged as a remarkable innovation to address the complex challenges of patients previously treated with SAVR and has rapidly gained prominence as a feasible technique especially in patients at high surgical risk. On the other hand, the expanding indications for TAVR in progressively younger patients with severe aortic stenosis pose the crucial question on the long-term durability of transcatheter heart valves (THVs), as patients might outlive the bioprosthetic valve. In this review, we provide an overview on the role of ViV TAVR for failed surgical and transcatheter BHVs, with a specific focus on current clinical evidence, pre-procedural planning, procedural techniques, and possible complications. The combination of integrated Heart Team discussion with interventional growth curve makes it possible to achieve best ViV TAVR results and avoid complications or put oneself ahead of time from them.

TAVR in TAVR: Where Are We in 2023 for Management of Failed TAVR Valves?

PURPOSE OF REVIEW

As TAVR is increasingly performed on younger patients with a longer life expectancy, the number of redo-TAVR procedures is likely to increase in the coming years. Limited data is currently available on this sometimes challenging procedure. We provide a summary of currently published literature on management of patients with a failed transcatheter aortic valve.

RECENT FINDINGS

Recent registry data have increased the clinical knowledge on redo-TAVR. Additionally, numerous bench studies have provided valuable insights into the technical aspects of redo-TAVR with various combinations of valve types. Redo-TAVR can be performed safely in selected cases with a high procedural success and good short-term outcomes. However, at present, the procedure remains relatively infrequent and many patients are not eligible. Bench testing can be useful to understand important concepts such as valve expansion, neoskirt, leaflet overhang, and leaflet deflection as well as their potential clinical implications.

Redo Transcatheter Aortic Valve Implantation in the Lotus Mechanically Expanded Transcatheter Heart Valve: Bench-Top Analysis, Clinical Experience, and Procedural Guidance

BACKGROUND

Redo transcatheter aortic valve implantation (TAVI) is increasing as patients outlive their transcatheter heart valves (THVs) and present with bioprosthetic valve failure. The Lotus mechanically expanded THV has unique design characteristics, which have specific implications for Redo TAVI.

METHODS

The design features of the Lotus valve and their relevance to Redo TAVI were reviewed. Bench-top analysis of Redo TAVI was performed using different contemporary THVs. Procedural and outcome data were obtained from 10 patients who had undergone Redo TAVI for Lotus bioprosthetic valve failure in 5 centers. Recommendations for performing Redo TAVI in Lotus are made, based on these findings.

RESULTS

The Lotus leaflets extend from the frame inflow, with a Neoskirt of only 13 mm, hence a low risk of coronary obstruction during Redo TAVI. The Lotus frame posts prevent full apposition of the Redo prosthesis in the upper part of the frame, while implantation of the Redo THV above the Lotus inflow leads to inadequate apposition of the Lotus leaflets. Inflow-to-inflow positioning is therefore recommended for effective sealing and leaflet pinning. The Lotus locking mechanism prevents overexpansion of the frame, limiting Redo THV oversizing. Redo TAVI was favorable with SAPIEN 3, Evolut, and Navitor THVs on bench-top analysis but not with ACURATE Neo 2 due to the upper crowns and short stent preventing inflow-to-inflow deployment. Case review demonstrated satisfactory outcomes in 10 patients treated with Evolut (n=6), SAPIEN 3 (n=3), and Portico (n=1) valves, with no mortality, major morbidity, or coronary obstruction. Three patients had residual mean gradient ≥20 mm Hg, including 2 of 3 SAPIEN cases. Guidance on procedural planning, valve choice, sizing, and positioning is provided.

CONCLUSIONS

Redo TAVI in Lotus requires an understanding of unique design characteristics, and adherence to key procedural recommendations, but can be safely and effectively performed with most contemporary valve types.

Feasibility of Redo-Transcatheter Aortic Valve Replacement in Sapien Valves Based on In Vivo Computed Tomography Assessment

BACKGROUND

Our aim was to assess the feasibility of repeat transcatheter aortic valve (TAV) replacement for degenerated Sapien3 (S3) prostheses by simulating subsequent implantation of S3 or Evolut, using in vivo computed tomography-based sizing and the impact on coronary and patient-prosthesis mismatch risks.

METHODS

Computed tomography scans from 356 patients with prior S3 TAV replacement implantation were analyzed. The in vivo sizing for second TAV based on averaged area of 3 levels of outflow, mid (narrowest) and inflow, was compared with in vitro recommendations, that is, same size as index S3 for second S3 and 1 size larger for Evolut. Risks of coronary obstruction and patient-prosthesis mismatch were determined by valve-to-aorta distance and estimated effective orifice area, respectively.

RESULTS

Overall, the majority of patients (n=328; 92.1%) had underexpanded index S3 with an expansion area of 94% (91%-97%), leading to significant differences in size selection of the second TAV between in vivo and in vitro sizing strategies. Expansion area <89% served as a threshold, resulting in 1 size smaller than the in vitro recommendations were selected in 45 patients (13%) for S3-in-S3 and 13 (4%) for Evolut-in-S3, while the remaining patients followed in vitro recommendations (P<0.01, in vivo versus in vitro sizing). Overall, 57% of total patients for S3-in-S3 simulation and 60% for Evolut-in-S3 were considered low risk for coronary complications. Deep index S3 implantation (odds ratio, 0.76 [interquartile range, 0.67-0.87]; P<0.001) and selecting Evolut as the second TAV (11% risk reduction in intermediate- or high-risk patients) reduced coronary risk. Estimated moderate or severe patient-prosthesis mismatch risk was 21% for S3-in-S3 and 1% for Evolut-in-S3, assuming optimal expansion of the second TAV.

CONCLUSIONS

Redo-TAV replacement with S3-in-S3 and Evolut-in-S3 could be feasible with low risk to coronaries in ≈60% of patients, while the remaining 40% will be at intermediate or high risk. The feasibility of redo-TAV replacement is influenced by sizing strategy, type of second TAV, native annular anatomy, and implant depth.

Incidence and Outcomes of Valve-in-Valve Transcatheter Aortic Valve Implantation in Failed Bioprosthetic Valves

INTRODUCTION

Transcatheter aortic valve replacement (TAVR) has become a widely used, comparably efficient and safe alternative to surgical aortic valve replacement (SAVR). Its utilization continues to grow, especially among younger patients. Despite improvements in durability, degeneration and subsequent re-interventions of failed prosthetic valves are still common. Even though valve-in-valve procedures have become more frequent, little is known about the trends over time or about clinical and echocardiographic long-term outcomes.

MATERIALS AND METHODS

Patients who underwent a valve-in-valve procedure between December 2011 and December 2022 in a large tertiary university hospital were analyzed. Primary outcomes were defined as procedural and device successes as well as event-free survival. Secondary analyses between subsets of patients divided by index valve and date of procedure were performed.

RESULTS

Among 1407 procedures, 58 (4%) were valve-in-valve interventions, with an increased frequency observed over time. Overall, technical success was achieved in 88% and device success in 85% of patients. Complications were predominantly minor, with similar success rates among TAVR-in-SAVR (TiSAVR) and TAVR-in-TAVR (TiTAVR). Notably, there were significant and lasting improvements in mean echocardiographic gradients at 1 year. Event-free survival was 76% at one month and 69% at one year.

CONCLUSIONS

Over the last decade, a rising trend of valve-in-valve procedures was observed. Despite an increase in procedures, complications show a contrasting decline with improved technical and device success over time. TiSAVR and TiTAVR showed comparable rates of procedural and device success as well as similar outcomes, highlighting the utility of valve-in-valve procedures in an aging population.

TAVR Interventions and Coronary Access: How to Prevent Coronary Occlusion

Due to technological advancements during the past 20 years, transcatheter aortic valve replacements (TAVRs) have significantly improved the treatment of symptomatic and severe aortic stenosis, significantly improving patient outcomes. The continuous evolution of transcatheter valve models, refined imaging planning for enhanced accuracy, and the growing expertise of technicians have collectively contributed to increased safety and procedural success over time. These notable advancements have expanded the scope of TAVR to include patients with lower risk profiles as it has consistently demonstrated more favorable outcomes than surgical aortic valve replacement (SAVR). As the field progresses, coronary angiography is anticipated to become increasingly prevalent among patients who have previously undergone TAVR, particularly in younger cohorts. It is worth noting that aortic stenosis is often associated with coronary artery disease. While the task of re-accessing coronary artery access following TAVR is challenging, it is generally feasible. In the context of valve-in-valve procedures, several crucial factors must be carefully considered to optimize coronary re-access. To obtain successful coronary re-access, it is essential to align the prosthesis with the native coronary ostia. As part of preventive measures, strategies have been developed to safeguard against coronary obstruction during TAVR. One such approach involves placing wires and non-deployed coronary balloons or scaffolds inside an at-risk coronary artery, a procedure known as chimney stenting. Additionally, the bioprosthetic or native aortic scallops intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure offers an effective and safer alternative to prevent coronary artery obstructions. The key objective of our study was to evaluate the techniques and procedures employed to achieve commissural alignment in TAVR, as well as to assess the efficacy and measure the impact on coronary re-access in valve-in-valve procedures.

Feasibility of redo-TAVI in self-expanding Evolut valves: a CT analysis from the Evolut Low Risk Trial substudy

BACKGROUND

Transcatheter aortic valve implantation in an existing transcatheter valve (redo-TAVI) pins the index valve leaflets in the open position (neoskirt), which can cause coronary flow compromise and limit access. Whether anatomy may preclude redo-TAVI in self-expanding Evolut valves is unknown.

AIMS

We aimed to evaluate the anatomical feasibility of redo-TAVI by simulating implantation of a balloon-expandable SAPIEN 3 (S3) within an Evolut or an Evolut within an Evolut.

METHODS

A total of 204 post-TAVI computed tomography (CT) scans from the Evolut Low Risk CT substudy were analysed. Five redo-TAVI positions were evaluated: S3-in-Evolut inflow-to-inflow, S3 outflow at Evolut nodes 4, 5, and 6, and Evolut-in-Evolut inflow-to-inflow. Univariable modelling identified pre-TAVI clinical characteristics, CT anatomical parameters, and procedural variables associated with coronary flow compromise using the neoskirt height and post-TAVI aortic root dimensions.

RESULTS

The risk of coronary flow compromise was lowest when the S3 outflow was at Evolut node 4 (20%) and highest when at Evolut node 6 (75%). The highest likelihood of preserving coronary accessibility occurred with the S3 outflow at Evolut node 4. Female sex and higher body mass index were associated with a higher risk of coronary flow compromise, as were a smaller annulus diameter, lower sinus of Valsalva height and width, shorter coronary height, smaller sinotubular junction diameter, and shallower Evolut implant depth.

CONCLUSIONS

The feasibility of redo-TAVI after Evolut failure is multifactorial and relates to the native annular anatomy, as well as the implantation depth of the index and second bioprostheses. Placement of an S3 at a lower Evolut position may reduce the risk of coronary flow compromise while preserving coronary access.

CLINICALTRIALS

gov: NCT02701283.

Redo transcatheter aortic valve replacement in degenerated transcatheter bioprosthesis (TAV-in-TAV)

INTRODUCTION

With the expanding indications of transcatheter aortic valve replacement (TAVR) to younger and low-risk patients, the life expectancy of patients currently undergoing TAVR will likely outlive the durability of transcatheter bioprosthesis. Consequently, the number of failed transcatheter bioprosthesis requiring surgical valve explant or redo TAVR is expected to increase.

AREAS COVERED

The aim of this review is to provide an updated overview of redo TAVR for treating degenerated transcatheter bioprosthesis, focusing on pre-procedural planning, potential challenges of coronary reaccess during TAVR-in-TAVR and main outcomes of TAVR explant and redo TAVR.

EXPERT OPINION

Patient-tailored device selection and individualized implantation height should be carefully assessed during the index TAVR procedure (weighting between pacemaker avoidance and the potential risk of coronary occlusion in future TAVR-in-TAVR). Future prospective studies comparing safety and clinical outcomes between redo TAVR vs TAVR explant are eagerly awaited.