Long-Term Outcomes Following Surgical Aortic Bioprosthesis Implantation

Minimally invasive approaches versus conventional sternotomy for aortic valve replacement in patients with aortic valve disease: a systematic review and meta-analysis of 17 269 patients

Background

Aortic valve replacement (AVR) is a common procedure for aortic valve pathologies, particularly in the elderly. While traditional open AVR is established, minimally invasive techniques aim to reduce morbidity and enhance treatment outcomes. The authors' meta-analysis compares these approaches with conventional sternotomy, offering insights into short and long-term mortality and postoperative results. This study provides valuable evidence for informed decision-making between conventional and minimally invasive approaches for AVR.

Materials and methods

Till August 2023, PubMed, Embase, and MEDLINE databases were searched for randomized controlled trials (RCT) and propensity score matched (PSM) studies comparing minimally invasive approaches [mini-sternotomy (MS) and right mini-thoracotomy (RMT)] with full sternotomy (FS) for AVR. Various outcomes were analyzed, including mortality rates, bypass and clamp times, length of hospital stay, and complications. Risk ratios (RR) and the weighted mean differences (WMD) with corresponding 95% CIs were calculated using Review Manager.

Results

Forty-eight studies were included having 17 269 patients in total. When compared to FS, there was no statistically significant difference in in-hospital mortality in MS (RR:0.80; 95% CI:0.50-1.27; I2=1%; P=0.42) and RMT (RR:0.70; 95% CI:0.36-1.35; I2=0%; P=0.29). FS was also linked with considerably longer cardiopulmonary bypass duration than MS (MD:8.68; 95% CI:5.81-11.56; I2=92%; P=0.00001). The hospital length of stay was determined to be shorter in MS (MD:-0.58; 95% CI:-1.08 to -0.09; I2=89%; P=0.02) with no statistically significant difference in RMT (MD:-0.67; 95% CI:-1.42 to 0.08; I2=84%; P=0.08) when compared to FS.

Conclusions

While mortality rates were comparable in minimally invasive approaches and FS, analysis shows that MS, due to fewer respiratory and renal insufficiencies, as well as shorter hospital and ICU stay, may be a safer approach than both RMT and FS.

Valve-in-Valve Transcatheter Aortic Valve Replacement Versus Redo-Surgical Aortic Valve Replacement in Patients With Aortic Stenosis: A Systematic Review and Meta-analysis

Aortic stenosis is a common and significant valve condition requiring bioprosthetic heart valves with transcatheter aortic valve replacement (TAVR) being strongly recommended for high-risk patients or patients over 75 years. This meta-analysis aimed to pool existing data on postprocedural clinical as well as echocardiographic outcomes comparing valve-in-valve (ViV)-TAVR to redo-surgical aortic valve replacement to assess the short-term and medium-term outcomes for both treatment methods. A systematic literature search on Cochrane Central, Scopus, and Medline (PubMed interface) electronic databases from inception to August 2023. We used odds ratios (OR) for dichotomous outcomes and mean differences (MD) for continuous outcomes. Twenty-four studies (25,216 patients) were pooled with a mean follow-up of 16.4 months. The analysis revealed that ViV-TAVR group showed a significant reduction in 30-day mortality (OR 0.50, 95% confidence interval [CI] 0.43 to 0.58, p <0.00001), new-onset atrial fibrillation (OR 0.34, 95% CI 0.17 to 0.67, p = 0.002), major bleeding event (OR 0.28, 95% CI 0.17 to 0.45, p <0.00001) and lower rate of device success (OR 0.25, 95% CI 0.12 to 0.53, p = 0.0003). There were no significant differences between either group when assessing 1-year mortality, stroke, myocardial infarction, postoperative left ventricular ejection fraction, and effective orifice area. ViV-TAVR cohort showed a significantly increased incidence of paravalvular leaks, aortic regurgitation, and increased mean aortic valve gradient. ViV-TAVR is a viable short-term option for older patients with high co-morbidities and operative risks, reducing perioperative complications and improving 30-day mortality with no significant cardiovascular adverse events. However, both treatment methods present similar results on short-term to medium-term complications assessment.

Role of lipoprotein(a) concentrations in bioprosthetic aortic valve degeneration

OBJECTIVES

Lipoprotein(a) (Lp(a)) is associated with an increased incidence of native aortic stenosis, which shares similar pathological mechanisms with bioprosthetic aortic valve (bAV) degeneration. However, evidence regarding the role of Lp(a) concentrations in bAV degeneration is lacking. This study aims to evaluate the association between Lp(a) concentrations and bAV degeneration.

METHODS

In this retrospective multicentre study, patients who underwent a bAV replacement between 1 January 2010 and 31 December 2020 and had a Lp(a) measurement were included. Echocardiography follow-up was performed to determine the presence of bioprosthetic valve degeneration, which was defined as an increase >10 mm Hg in mean gradient from baseline with concomitant decrease in effective orifice area and Doppler Velocity Index, or new moderate/severe prosthetic regurgitation. Levels of Lp(a) were compared between patients with and without degeneration and Cox regression analysis was performed to investigate the association between Lp(a) levels and bioprosthetic valve degeneration.

RESULTS

In total, 210 cases were included (mean age 74.1±9.4 years, 72.4% males). Median time between baseline and follow-up echocardiography was 4.4 (IQR 3.7) years. Bioprostheses degeneration was observed in 33 (15.7%) patients at follow-up. Median serum levels of Lp(a) were significantly higher in patients affected by degeneration versus non-affected cases: 50.0 (IQR 72.0) vs 15.6 (IQR 48.6) mg/dL, p=0.002. In the regression analysis, high Lp(a) levels (≥30 mg/dL) were associated with degeneration both in a univariable analysis (HR 3.6, 95% CI 1.7 to 7.6, p=0.001) and multivariable analysis adjusted by other risk factors for bioprostheses degeneration (HR 4.4, 95% CI 1.9 to 10.4, p=0.001).

CONCLUSIONS

High serum Lp(a) is associated with bAV degeneration. Prospective studies are needed to confirm these findings and to investigate whether lowering Lp(a) levels could slow bioprostheses degradation.

Long-term risk of reintervention after transcatheter aortic valve replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) has surpassed surgical aortic valve replacement (SAVR) as the predominant mode of valve replacement for the treatment of severe aortic stenosis (AS). However, the long-term need for valvular reintervention after TAVR remains unknown.

METHODS

Using data from the Medicare Fee for Service 100% dataset, all patients receiving TAVR between July 2011 and December 2020 were identified. Patients were categorized as receiving a valve reintervention (either surgical or transcatheter) or not using the appropriate International Classification of Diseases 10th Revision Procedure Coding System (ICD-10-PCS). A competing risk regression model was used to estimate the cumulative probability of valve reintervention.

RESULTS

Of 230,644 TAVR patients were identified, of whom 1,880 received a reintervention. Patients receiving a reintervention were younger and more likely to be male. At 10 years, the crude rate of reintervention was 0.59% within a surviving cohort of 341 patients. After adjusting for the competing risk of death and other covariates, the adjusted cumulative incidence of reintervention at 10 years after TAVR was 1.63%. When the rate of reinterventions was compared between early (2011-2016) and later (2017-2020) time periods, the risk-adjusted rate of reintervention at 4 years had decreased over time (0.85% vs 0.51%).

CONCLUSION

The 10-year risk of valve reintervention after TAVR is low and appears to be decreasing over time. Further research is necessary to determine the driving factors contributing to valve reintervention in the current era.

Ten years' experience with the sutureless aortic valve replacement: incidence and predictors for survival and valve durability at follow-up

OBJECTIVES

Aortic valve replacement with a sutureless prosthesis [sutureless aortic valve replacement (Su-AVR)] is an option for patients with severe aortic valve stenosis. However, data regarding long-term outcomes and prosthesis durability are still lacking.

METHODS

All consecutive patients who successfully underwent Su-AVR with the Perceval valve in our centre between 2010 and 2020 were included in the analysis and followed prospectively with echocardiography. Risk factor analysis was performed to assess variables associated with worse survival and bioprosthetic valve failure.

RESULTS

Study population consisted of 547 patients: the mean age was 76.4 (5.2) years, 51% were female and the mean logistic EuroSCORE was 13% (11). The median survival was 7.76 years [95% confidence interval (CI) = 6.9-8.6]. Risk factor analysis identified age [hazard ratio (HR) 1.06, 95% CI 1.03-1.11; P < 0.001), EuroSCORE II (HR 1.08, 1.02-1.13; P < 0.001), baseline dialysis (HR 2.14, 95% CI 1.4-4.4; P = 0.038) and postoperative acute kidney injury ≥2 (HR 8.97, 95% CI 4.58-17.6; P < 0.001) as factors significantly correlated with worse survival. The reported HRs for age are per 1 year and for EuroSCORE II is 1 percentage point. Structural valve deterioration (SVD) was observed in 23 patients, of whom 19 underwent reintervention (median freedom from SVD 10.3 years). In multivariable Cox analysis, age (HR 0.89, 95% CI 0.82-0.95; P < 0.001) was found to be a significant predictor of SVD. Overall, 1.8% was referred for prosthetic valve endocarditis (confirmed or suspected) during follow-up. One patient showed moderate non-SVD and none developed prosthetic valve thrombosis.

CONCLUSIONS

The sutureless valve represents a reliable bioprosthesis for aortic valve replacement in patients with a 10-year life expectancy. Younger age at the time of implant is the only factor associated with the risk of long-term SVD.

Redo Surgical Aortic Valve Replacement versus Valve-In-Valve Transcatheter Aortic Valve Implantation: A Systematic Review and Reconstructed Time-To-Event Meta-Analysis

Objective. Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) has emerged as a useful alternative intervention to redo-surgical aortic valve replacement (Redo-SVAR) for the treatment of degenerated bioprosthesis valve. However, there is no robust evidence about the long-term outcome of both treatments. The aim of this meta-analysis was to analyze the long-term outcomes of Redo-SVAR versus ViV-TAVI by reconstructing the time-to-event data. Methods. The search strategy consisted of a comprehensive review of relevant studies published between 1 January 2000 and 30 September 2022 in three electronic databases, PubMed, Cochrane Central Register of Controlled Trials (CENTRAL) and EMBASE. Relevant studies were retrieved for the analysis. The primary endpoint was the long-term mortality for all death. The comparisons were made by the Cox regression model and by landmark analysis and a fully parametric model. A random-effect method was applied to perform the meta-analysis. Results. Twelve studies fulfilled the eligibility criteria and were included in the final analysis. A total of 3547 patients were included. Redo-SAVR group included 1783 patients, and ViV-TAVI included 1764 subjects. Redo-SAVR showed a higher incidence of all-cause mortality within 30-days [Hazard ratio (HR) 2.12; 95% CI = 1.49−3.03; p < 0.0001)], whereas no difference was observed between 30 days and 1 year (HR = 1.03; 95% CI = 0.78−1.33; p = 0.92). From one year, Redo-SAVR showed a longer benefit (HR = 0.52; 95% CI = 0.40−0.67; p < 0.0001). These results were confirmed for cardiovascular death (HR = 2.04; 95% CI = 1.29−3.22; p = 0.001 within one month from intervention; HR = 0.35; 95% CI = 0.18−0.71; p = 0.003 at 4-years follow-up). Conclusions. Although the long-term outcomes seem similar between Redo-SAVR and ViV-TAVI at a five-year follow-up, ViV-TAVI shows significative lower mortality within 30 days. This advantage disappeared between 30 days and 1 year and reversed in favor of redo-SAVR 1 year after the intervention.

Minimally invasive versus conventional aortic valve replacement: The network meta-analysis

BACKGROUND

Outcome comparisons after surgical aortic valve replacement (SAVR) with minimally invasive approaches including mini-sternotomy (MS) and right mini-thoracotomy (RMT) and full sternotomy (FS) have been conflicting. Furthermore, the synthesis of mid-term mortality has not been performed.

METHODS

MEDLINE and EMBASE were searched through April 2022 to identify propensity score matched (PSM) studies or randomized controlled trial (RCT) which compared outcomes following SAVR among three incisional approaches: FS, MS, or RMT. The network analysis was performed to compare these approaches with random effects model. Mid-term mortality was defined as 1-year mortality.

RESULTS

A total of 42 studies met the inclusion criteria enrolling 14,925 patients. RCT and PSM were performed in 13 and 29 studies, respectively. The operative mortality was significantly lower with MS compared to FS (risk ratio [RR]: 0.60, 95% confidence interval [CI]: 0.41-0.90, p = .01, I²  = 25.8%) or RMT (RR: 0.51, 95% CI: 0.27-0.97, p = .03, I²  = 25.8%). RMT had significantly higher risk of reoperation for bleeding compared to MS (RR: 1.65, 95% CI: 1.18-2.30, p = .003, I²  = 0%). Hospital length of stay was significantly shorter with MS compared to FS (mean difference: -0.89 days, 95% CI: -1.58 to -0.2, p = .01, I²  = 95.5%) while it was equivocal between FS and RMT. The mid-term mortality was similar among the three approaches.

CONCLUSIONS

While mid-term mortality was comparable among approaches, MS may be a safe and potentially more effective approach than FS and RMT for SAVR in the short term.

Macroscopic and microscopic features of surgically explanted transcatheter aortic valve prostheses

OBJECTIVES

With the extended indications of transcatheter aortic valve (TAV) replacement (TAVR) to lower-risk patients, there is an increasing number of patients requiring surgical explantation of failed TAV. We sought to describe macroscopic and microscopic features of surgically explanted percutaneous aortic valve prostheses.

METHODS

Preoperative and surgical characteristic of patients undergoing surgical explantation of TAV were retrospectively analyzed from 2007 to 2020. Surgical and pathologic features of these valves, and outcomes of the surgical valve replacement were described.

RESULTS

Out of 1764 patients who underwent a TAVR procedure, 21 were operated for TAV failure. Isolated or combined indications for surgery included: significant paravalvular leak (n = 15), delayed prosthesis migration (n = 5), significant increase of trans-TAV gradients (n = 6), and endocarditis (n = 3). Mean time elapsed between TAVR and explantations was 674.9 ± 803.9 days. Macroscopic lesions found on explanted percutaneous valves were severe adhesions to the aorta (n = 10), calcifications (n = 7), leaflet thrombosis (n = 4), and vegetations (n = 3). Except for patients with endocarditis, one or more pathological lesions were found in 15 patients. Pathology analyses on these valves showed fibro-calcific degenerations (n = 12), pannus formation (n = 9), and chronic inflammation (n = 3). One patient (4.8%) died after surgical explantation, and 13 (61.9%) had concomitant procedures. The survival rate at 1 year was 94.4%.

CONCLUSIONS

Microscopic findings of fibro-calcific leaflet degeneration, and pannus formation in addition to macroscopic calcification and thrombosis present early, (within a mean of 2 years) after TAVR. Further investigation with a higher number of patients and echocardiographic follow-up is warranted.

Cardiac Computed Tomography: Application in Valvular Heart Disease

The incidence and prevalence of valvular heart disease (VHD) is increasing and has been described as the next cardiac epidemic. Advances in imaging and therapeutics have revolutionized how we assess and treat patients with VHD. Although echocardiography continues to be the first-line imaging modality to assess the severity and the effects of VHD, advances in cardiac computed tomography (CT) now provide novel insights into VHD. Transcatheter valvular interventions rely heavily on CT guidance for procedural planning, predicting and detecting complications, and monitoring prosthesis. This review focuses on the current role and future prospects of CT in the assessment of aortic and mitral valves for transcatheter interventions, prosthetic valve complications such as thrombosis and endocarditis, and assessment of the myocardium.

Why Does the NOTION Trial Show Poorer Than Expected Outcomes in the Surgical Arm?

The NOTION trial compares transcatheter aortic valve implantation versus surgical aortic valve replacement in low-risk patients. Looking carefully at the outcomes of this trial, there is no doubt that the transcatheter aortic valve implantation results were outstanding. The same thing cannot be said for the results of the surgery. We tried to understand the reason for that.

Trend and early outcomes in isolated surgical aortic valve replacement in the United Kingdom

Objective

Surgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early clinical outcomes, and the choice of prosthesis use in isolated SAVR in the United Kingdom.

Methods

All patients (n = 79,173) who underwent elective or urgent isolated surgical aortic valve replacement (SAVR) from 1996 to 2018 were extracted from the National Adult Cardiac Surgery Audit database. Patients who underwent additional procedures and emergency or salvage SAVR were excluded from the study. Trend and clinical outcomes were investigated in the whole cohort. Patients who had previous cardiac surgery, high-risk groups (EuroSCORE II >4%), and predicted/observed mortality were evaluated. Furthermore, the use of biological prostheses in five different age groups, that are <50, 50-59, 60-69, 70-79, and >80, was investigated. Clinical outcomes between the use of mechanical and biological aortic valve prostheses in patients <65 years old were analyzed.

Results

The number of isolated SAVR increased across the study period with an average of 4,661 cases performed annually after 2010. The in-hospital/30-day mortality rate decreased from 5.28% (1996) to 1.06% (2018), despite an increasing trend in EuroSCORE II. The number of isolated SAVR performed in octogenarians increased from 596 to 2007 (the first year when TAVR was introduced in the UK) to 872 in 2015 and then progressively decreased to 681 in 2018. Biological prosthesis usage increased across all age groups, particularly in the 60-69 group, from 24.59% (1996) to 81.87% (2018). There were no differences in short-term outcomes in patients <65 years old who received biological or mechanical prostheses.

Conclusion

Surgical aortic valve replacement remains an effective treatment for patients with isolated aortic valve disease with a low in-hospital/30-day mortality rate. The number of patients with high-risk and octogenarians who underwent isolated SAVR and those requiring redo surgery has reduced since 2016, likely due to the advancement in TAVR. The use of biological aortic prostheses has increased significantly in recent years in all age groups.

Predictive Model for Thrombus Formation After Transcatheter Valve Replacement

PURPOSE

Leaflet thrombosis is a significant adverse event after transcatheter aortic valve (TAV) replacement (TAVR). The purpose of our study was to present a semi-empirical, mathematical model that links patient-specific anatomic, valve, and flow parameters to predict likelihood of leaflet thrombosis.

METHODS

The two main energy sources of neo-sinus (NS) washout after TAVR include the jet flow downstream of the TAV and NS geometric change in volume due to the leaflets opening and closing. Both are highly dependent on patient anatomic and hemodynamic factors. As rotation of blood flow is prevalent in both the sinus of Valsalva and then the NS, we adopted the vorticity flux or circulation (Г) as a metric quantifying overall washout. Leaflet thrombus volumes were segmented based on hypo-attenuating leaflet thickening (HALT) in post-TAVR patient's gated computed tomography. Г was assessed using dimensional scaling as well as computational fluid dynamics (CFD) respectively and correlated to the thrombosis volumes using sensitivity and specificity analysis.

RESULTS

Г in the NS, that accounted for patient flow and anatomic conditions derived from scaling arguments significantly better predicted the occurrence of leaflet thrombus than CFD derived measures such as stasis volumes or wall shear stress. Given results from the six patient datasets considered herein, a threshold Г value of 28.0 yielded a sensitivity and specificity of 100% where patients with Gamma < 28 developed valve thrombosis. A 10% error in measurements of all variables can bring the sensitivity specificity down to 87%.

CONCLUSION

A predictive model relating likelihood of valve thrombosis using Г in the NS was developed with promising sensitivity and specificity. With further studies and improvements, this predictive technology may lead to alerting physicians on the risk for thrombus formation following TAVR.

Impact of Non-Valvular Non-Coronary Concomitant Procedures on Outcomes of Surgical Aortic Valve Replacement in Intermediate Risk Patients

Introduction: advanced age and concomitant procedures could increase the risk of perioperative complications during surgical aortic valve replacement (SAVR). We aimed to evaluate results of elderly patients undergoing SAVR and evaluate the impact of concomitant non-valvular, non-coronary procedures on the outcomes. Methods: A retrospective single-centre study, evaluating 464 elderly patients (mean age = 75.6 ± 4 years) undergoing either isolated-SAVR (I-SAVR = 211) or combined-SAVR (C-SAVR = 253) between 01/2007 and 12/2017. Combined-SAVR involved non-valvular, non-coronary procedures. Study endpoints are postoperative results concerning the VARC-II criteria, valve dysfunction, long-term freedom from redo-AVR and survival. Results: males were 52.8%. Patients had an intermediate risk profile (mean EuroSCORE-II (%) 5.2 ± 5). Postoperative results reported no significant differences in incidence of re-exploration for bleeding (6.6% vs. 6.7%, p = 1.0), stroke (0.9% vs. 0.4%, p = 0.59), dialysis (6.2% vs. 9.5%, p = 0.23) and pacemaker implantation (3.3% vs. 2.8%, p = 0.79) between I-SAVR and C-SAVR groups. Thirty-day (2.4% vs. 7.1% p = 0.03), one-year (5.7% vs. 13.8%, p = 0.003) and overall mortality (24.6% vs. 37.5%, p = 0.002) were lower in the isolated-SAVR group. Re-AVR was indicated in 1.7% of patients due to endocarditis. Conclusions: SAVR in elderly patients offers good outcomes with increased life quality and rare re-operation for structural valvular deterioration. Mortality rates were significantly higher when SAVR was combined with another “non-valvular, non-coronary” procedure.

Transcatheter solutions for transcatheter aortic valve replacement dysfunction: is redo transcatheter aortic valve replacement a durable option?

As transcatheter aortic valve replacement (TAVR) expands into a younger and lower risk cohort of patients, many important clinical questions are raised, including the one of overall valve durability. Bioprosthetic valve dysfunction (BVD) is a complex clinical issue, of which structural valve deterioration (SVD) is a subcategory. Similar to surgical bioprosthesis, transcatheter heart valves (THVs) can fail over the years however, data on long-term THVs durability is lacking, especially in the lower risk cohort. Surgical explant with open aortic surgery or a second THV, described as redo-TAVR, are feasible options when the first THV fails. However long-term data in these patients is even more limited. Important clinical considerations such as the mechanism(s) of THV dysfunction, the type and timing of the second procedure must be carefully considered. There are also inherently important clinical concerns regarding redo-TAVR, such as coronary access and higher post procedure gradients. In the present keynote lecture, we review the diagnosis of THV dysfunction and transcatheter options available when SVD occurs.

A systematic review on durability and structural valve deterioration in TAVR and surgical AVR

Mechanical valves and bioprosthetic heart valves are widely used for aortic valve replacement (AVR). Mechanical valves are associated with risk of bleeding because of oral anticoagulation, while the durability and structural valve deterioration (SVD) represent the main limitation of the bioprosthetic heart valves. The implantation of bioprosthetic heart valves is increasing precipitously due aging population, and the widespread use of transcatheter aortic valve replacement (TAVR). TAVR has become the standard treatment for intermediate or high surgical risk patients and a reasonable alternative to surgery for low risk patients with symptomatic severe aortic stenosis. Moreover, TAVR is increasingly being used for younger and lower-risk patients with longer life expectancy; therefore it is important to ensure the valve durability for long-term transcatheter aortic valves. Although the results of mid-term durability of the transcatheter heart valves are encouraging, their long-term durability remains largely unknown. This review summarises the definitions, mechanisms, risk factors and assessment of SVD; overviews available data on surgical bioprosthetic and transcatheter heart valves durability.

Transcatheter valve-in-valve implantation in degenerated surgical aortic and mitral bioprosthesis: Current state and future perspectives

The use of bioprosthetic valves for treating patients with severe valve disease has increased over the last 2 decades, and, as a consequence, a growing number of patients with failing surgical bioprosthesis is expected in the near future. In this setting, valve-in-valve (ViV) transcatheter aortic/mitral valve replacement (TAVR and TMVR) has emerged as an alternative to redo surgery. Despite the increasing experience in ViV procedures, the development of these techniques faces several specific challenges, mainly related to the unique anatomical and physiological characteristics presented in ViV-TAVR/TMVR. Subsequently, various approaches have been proposed to overcome ViV-related complications and pitfalls. A growing body of evidence is currently available concerning early- and long-term clinical outcomes of patients undergoing ViV-TAVR/TMVR. These data should be comprehensively evaluated by the Heart Team in the decision-making process involving patients with failing surgical bioprostheses. In this review, we aimed to delineate the technical challenges and risks associated with ViV-TAVR and ViV-TMVR, provide an updated overview of the main clinical results, and summarize the future perspectives of this evolving field.

A novel cardiovascular magnetic resonance risk score for predicting mortality following surgical aortic valve replacement

The increasing prevalence of patients with aortic stenosis worldwide highlights a clinical need for improved and accurate prediction of clinical outcomes following surgery. We investigated patient demographic and cardiovascular magnetic resonance (CMR) characteristics to formulate a dedicated risk score estimating long-term survival following surgery. We recruited consecutive patients undergoing CMR with gadolinium administration prior to surgical aortic valve replacement from 2003 to 2016 in two UK centres. The outcome was overall mortality. A total of 250 patients were included (68 ± 12 years, male 185 (60%), with pre-operative mean aortic valve area 0.93 ± 0.32cm², LVEF 62 ± 17%) and followed for 6.0 ± 3.3 years. Sixty-one deaths occurred, with 10-year mortality of 23.6%. Multivariable analysis showed that increasing age (HR 1.04, P = 0.005), use of antiplatelet therapy (HR 0.54, P = 0.027), presence of infarction or midwall late gadolinium enhancement (HR 1.52 and HR 2.14 respectively, combined P = 0.12), higher indexed left ventricular stroke volume (HR 0.98, P = 0.043) and higher left atrial ejection fraction (HR 0.98, P = 0.083) associated with mortality and developed a risk score with good discrimination. This is the first dedicated risk prediction score for patients with aortic stenosis undergoing surgical aortic valve replacement providing an individualised estimate for overall mortality. This model can help clinicians individualising medical and surgical care.

Trial Registration ClinicalTrials.gov Identifier: NCT00930735 and ClinicalTrials.gov Identifier: NCT01755936.

Reintervention rates following bioprosthetic surgical aortic valve replacement-a Danish Nationwide Cohort Study

OBJECTIVES

Updated European guidelines recommend annual echocardiographic evaluation after bioprosthetic surgical aortic valve replacement (bio-SAVR). Given the increased demand on health care resources, only clinically relevant controls can be prioritized. We therefore aimed to explore reintervention rates following bio-SAVR.

METHODS

From the nationwide Danish Register of Surgical Procedures, we identified all patients ≥40 years with isolated bio-SAVR ± concomitant coronary artery bypass graft surgery (CABG) during 2000-2016. In 90-day reintervention-free survivors, we assessed aortic valve reintervention rates (primary outcome) and all-cause mortality rates (secondary outcome) at 1, 3 and 5 years with total follow-up until 31 December 2017 and further estimated annual theoretical echocardiographic control visits.

RESULTS

In 10 518 patients with bio-SAVR (+CABG 39.7%), we observed low reintervention rates at 1, 3 and 5 years, but with high rates of all-cause mortality; i.e. 5-year reintervention rate of 3.7/1000 person-years (≤1.5%) and 5-year mortality rate of 21.7/1000 person-years. Accounting for the competing risk of death, 5-year rates were inversely related to age group and remained relatively low across all age categories but increased gradually in the long term. A significant proportion of reinterventions were presumed due to infectious endocarditis (48% at 3 years, 37% at 5 years). With annual transthoracic echocardiography, the theoretical ratio of echocardiographies per reintervention in the first 5 years was 248, and 425 when endocarditis events were excluded.

CONCLUSION

Reintervention rates within the first 5 years following bio-SAVR were relatively rare, and with a substantial number due to endocarditis.

Transcatheter aortic valve implantation in low-risk patients: A case of rational over exuberance. The time is not now

BACKGROUND

Review of evidence and concerns, relating to extension of transcatheter aortic valve implantation usage to low-risk patients.

METHODS

Comprehensive literature review was conducted identifying articles relating to transcatheter aortic valve implantation.

RESULTS

Transcatheter aortic valve implantation is effective in patients with aortic stenosis. Currently, long-term durability and cost-effectiveness are unproven, anticoagulation requirement undefined, permanent pacemaker implantation and paravalvular leak rates higher than following surgical aortic valve replacement.

CONCLUSIONS

Current evidence supporting transcatheter aortic valve implantation usage in low-risk patients is insufficient. Extending use now, to this large young patient population is premature, and should be delayed.

Hemodynamically significant prosthesis-patient mismatch can be predicted and is associated with early prosthetic valve dysfunction in aortic bioprosthesis

OBJECTIVES

To evaluate the accuracy of predicted prosthesis-patient mismatch (PPM) regarding actual PPM measured postoperatively. To assess the association between PPM and prosthetic valve dysfunction.

METHODS

Retrospective cohort study including adult patients after aortic valve replacement surgery with a biological prosthesis. Predicted PPM status was determined using mean reference effective orifice area indexed to total body surface (iEOA), without considering reference standard deviations. Postoperative PPM status was determined by measuring iEOA within the first 60 postoperative days. Prosthetic valve dysfunction was defined as thrombosis, pannus, valve degeneration, and/or disruption.

RESULTS

205 patients were enrolled between January 2003 and June 2017: predicted PPM was absent in 52 patients (25.4%), moderate in 137 patients (66.8%), and severe in 16 patients (7.8%). After surgery, the actual postoperative iEOA was measured: 53 (25.9%) did not have PPM, 73 had moderate PPM (35.6%), and 79 had severe PPM (38.5%). Predicted PPM identified the presence of hemodynamically significant actual postoperative PPM (OR = 2.56; 95%CI 1.30-5.05; P = .006), though not its degree of severity. Prosthetic valve dysfunction was more frequent among patients with hemodynamically significant PPM (53.9% vs. 11.3%; P < .001), compared to those without PPM. The association between PPM and prosthetic valve dysfunction was maintained after adjusting for gender, age, and ever-smoking (OR = 9.03; P < .001). The incidence of thrombosis or pannus was also nonsignificantly higher in patients with moderate or severe PPM.

CONCLUSIONS

Predicted PPM identifies the presence, possibly not the severity, of actual postoperative PPM. Moderate or severe PPM is associated with prosthetic valve dysfunction. Actual postoperative prosthesis-patient mismatch measured within 60 postoperative days showed a distinctive hemodynamic profile and presented a stronger association with prosthetic valve dysfunction than predicted prosthesis-patient mismatch. A. Echocardiographic follow-up in patients according to the actual postoperative PPM measured within 60 postoperative days. B. Prediction of prosthetic valve dysfunction based on preoperative predicted PPM or on actual postoperative PPM within 60 postoperative days. PPM: prosthesis-patient mismatch. OR: Odds ratio.

Sutureless Valve in Repeated Aortic Valve Replacement: Results from an International Prospective Registry

OBJECTIVE

To report early and midterm results registry of patients undergoing repeated aortic valve replacement (RAVR) with sutureless prostheses from an international prospective registry (SURE-AVR).

METHODS

Between March 2011 and June 2019, 69 patients underwent RAVR with self-expandable sutureless aortic bioprostheses at 22 international cardiac centers.

RESULTS

Overall mortality was 2.9% with a predicted logistic EuroSCORE II of 10.7%. Indications for RAVR were structural valve dysfunction (84.1%) and infective prosthetic endocarditis (15.9%) and were performed in patients with previously implanted bioprostheses (79.7%), mechanical valves (15.9%), and transcatheter valves (4.3%). Minimally invasive approach was performed in 15.9% of patients. Rate of stroke was 1.4% and rate of early valve-related reintervention was 1.4%. Overall survival rate at 1 and 5 years was 97% and 91%, respectively. No major paravalvular leak occurred. Rate of pacemaker implantation was 5.8% and 0.9% per patient-year early and at follow-up, respectively. The mean transvalvular gradient at 1-year and 5-year follow-up was 10.5 mm Hg and 11.5 mm Hg with a median effective orifice area of 1.8 cm²and 1.8 cm², respectively.

CONCLUSIONS

RAVR with sutureless valves is a safe and effective approach and provides excellent clinical and hemodynamic results up to 5 years.

Valve-in-valve transcatheter aortic valve replacement versus redo surgical aortic valve replacement: A systematic review and meta-analysis

BACKGROUND/AIM

With the growing contemporary use of bioprosthetic valves, whose limited long-term durability has been well-documented, an increase in the need for reintervention is expected. We perform a meta-analysis to compare the current standard of care, redo surgical aortic valve replacement (Redo SAVR) with the less invasive alternative, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) for treating structural valve deterioration.

METHODS

After a comprehensive literature search, studies comparing ViV TAVR to Redo SAVR were pooled to perform a pairwise meta-analysis using the random-effects model. Primary outcomes were 30-day and follow-up mortality.

RESULTS

A total of nine studies including 9127 patients were included. ViV TAVR patients were significantly older (mean difference [MD], 5.82; p = .0002) and more frequently had hypercholesterolemia (59.7 vs. 60.0%; p = .0006), coronary artery disease (16.1 vs. 16.1%; p = .04), periphery artery disease (15.4 vs. 5.7%; p = .004), chronic obstructive pulmonary disease (29.3 vs. 26.2%; p = .04), renal failure (30.2 vs. 24.0%; p = .009), and >1 previous cardiac surgery (23.6 vs. 15.9%; p = .004). Despite this, ViV TAVR was associated with decreased 30-day mortality (OR, 0.56; p < .0001). Conversely, Redo SAVR had lower 30-day paravalvular leak (OR, 6.82; p = .04), severe patient-prosthesis mismatch (OR, 3.77; p < .0001), and postoperative aortic valve gradients (MD, 5.37; p < .0001). There was no difference in follow-up mortality (HR, 1.02; p = .86).

CONCLUSIONS

Despite having patients with an increased baseline risk, ViV TAVR was associated with lower 30-day mortality, while Redo SAVR had lower paravalvular leak, severe patient-prosthesis mismatch, and postoperative gradients. Although ViV TAVR remains a feasible treatment option in high-risk patients, randomized trials are necessary to elucidate its efficacy over Redo SAVR.

Aortic valve replacement in patients over 60: Real-world surgical outcomes

OBJECTIVE

With the advent of transcatheter aortic valve implantation (TAVI) has come an expectation that there will be a decline in surgical aortic valve replacement (SAVR). This has been fueled by trials comparing outcomes between TAVI and SAVR in lower-risk patients. The aim of this study was to examine outcomes following SAVR in patients over the age of 60.

MATERIALS AND METHODS

This retrospective cohort study observed 1005 patients ≥60 who underwent isolated primary SAVR from January 2015 to December 2018. The cohort was stratified by surgical risk, defined as European System for Cardiac Operative Risk Evaluation (EuroSCORE) II < 4 versus ≥4. The cohort was also divided by age (60-69, 70-79, ≥80) for additional comparisons. Outcomes included in-hospital complications and patient survival.

RESULTS

The median age and EuroSCORE II were 75 years and 1.6, respectively. The overall 30-day mortality was 1.7% and increased significantly with surgical risk (p = .007). The 30-day mortality of elective patients was 1.1%. Overall, 1- and 2-year survival rates were 94.3% and 91.7%, respectively, which significantly decreased with surgical risk (p < .001) and age (p = .002, p = .003). The rates of postoperative stroke and pacemaker implantations were 1.2% and 3.6%, respectively.

CONCLUSIONS

SAVR can be performed in patients ≥60 years old with excellent outcomes, which compare favorably with outcomes from TAVI trials, with their highly selected patient cohorts. SAVR remains a reliable, tried and tested, treatment option in these patients.

History, development and clinical perspectives of sutureless and rapid deployment surgical aortic valve replacement

Degenerative aortic stenosis is the most frequent valvular heart disease in industrialized countries. Conservative treatment may beneficially influence symptoms but is never successful. Surgical aortic valve replacement (SAVR) was the only recognized treatment option to provide substantially prolonged survival until 2008. Operative mortality of isolated SAVR has been reported as low as 0.5% to 1% in experienced institutions, while long-term survival is close to that observed in a control healthy population of similar age. A multitude of studies have demonstrated the beneficial effects of SAVR with regard to improvement in quality of life and physical performance in the majority of symptomatic patients. In the last decade, transcatheter aortic valve implantation (TAVI) has emerged as an equal treatment modality, first in patients with high surgical risk and more recently in patients with intermediate and low surgical risk. Paravalvular regurgitation and the higher rate of pacemaker implantation remain points of consideration. Additionally, the long-term durability of TAVI devices and occurrence of stroke late after TAVI require additional analyses. Sutureless (SU-SAVR) and rapid deployment valve (R-SAVR) were designed to simplify and accelerate a conventional or less invasive surgical procedure while allowing complete excision of the calcified native valve. From 3 different implants tested more than 10 to 15 years ago, only two are available on the market today: the Perceval^® valve from Liva Nova and the Intuity^® sutureless prosthesis from Edwards Lifesciences. There has been extensive experience with these two devices in previous years and the results obtained are comparable to those observed following the use of conventional implants. The sutureless devices may be of particular interest for more complex and combined surgical procedures. This review summarizes the sutureless (SU-SAVR) and rapid deployment valve technologies and presents a clinical outlook for the patient population managed with these devices.

Subclinical Structural Valve Degeneration in Young Patients With Bioprosthetic Aortic Valves

BACKGROUND

Bioprosthetic structural valve degeneration (SVD) has previously been a clinical diagnosis, but subclinical changes have been increasingly recognized in transcatheter valves. The significance of subclinical SVD after surgical aortic valve replacement (SAVR), however, is not well understood. The purpose of this study was to characterize the incidence and outcomes of subclinical SVD in young patients after SAVR.

METHODS

Patients aged ≤65 years who underwent bioprosthetic SAVR between January 2002 and June 2018 at a single institution were included. Endocarditis cases and those with in-hospital mortality were excluded. All available longitudinal postoperative echocardiograms were reviewed. Subclinical SVD was defined as an increase in mean transvalvular gradient of at least 10 mm Hg and/or new onset of mild intraprosthetic regurgitation or increase by at least 1 grade, compared with baseline postoperative echocardiogram.

RESULTS

Overall, 822 unique SAVR cases were included. Over the study period, 356 (43.3%) patients developed subclinical SVD. Only 21.5% of those with subclinical SVD progressed to clinical SVD or to repeat aortic valve procedures. In those with progression, the first signs of SVD occurred significantly earlier than in those whose changes remained stable (11 months vs 23 months; P = .036). Anticoagulation did not impact the development or progression of subclinical SVD. There was no difference in long-term survival for those who did or did not develop subclinical SVD.

CONCLUSIONS

Subclinical SVD occurred in a large proportion of young patients undergoing bioprosthetic SAVR. Despite its high prevalence, subclinical SVD was not associated with decreased survival or repeat procedures.

Long-term Outcomes Following Mechanical or Bioprosthetic Aortic Valve Replacement in Young Women

Background

Studies performed to date reporting outcomes after mechanical or bioprosthetic aortic valve replacement (AVR) have largely neglected the young female population. This study compares long-term outcomes in female patients aged < 50 years undergoing AVR with either a mechanical or bioprosthetic valve.

Methods

In this propensity-matched study, we compared outcomes after mechanical AVR (n = 57) and bioprosthetic AVR (n = 57) between 2004 and 2018. The primary outcome of this study is survival. Secondary outcomes include the rate of reoperation, stroke, myocardial infarction, rehospitalization for heart failure, and incidence of serious adverse events. Outcomes were measured over 15 years, with a median follow-up of 7.8 years.

Results

In patients receiving a mechanical AVR vs a bioprosthetic AVR, overall survival at median follow-up was equivalent, at 93%. There is a lower rate of reoperation in patients receiving a mechanical AVR vs a bioprosthetic AVR (1.8% vs 8.8%). The rate of new-onset atrial fibrillation was significantly higher in the mechanical AVR group vs the bioprosthetic AVR group (18.2% vs 7.3%). No significant difference was seen in the rate of serious adverse events.

Conclusions

These results provide contemporary data demonstrating equivalent long-term survival between mechanical and bioprosthetic AVR, with higher rates of new atrial fibrillation after mechanical AVR, and higher rates of reoperation after bioprosthetic AVR. These results suggest that either valve type is safe, and that preoperative assessment and counselling, as well as the follow-up, medical treatment and indications for intervention, must be a collaborative decision-making process between the clinician and the patient.

Biomarkers of aortic bioprosthetic valve structural degeneration

PURPOSE OF REVIEW

Bioprosthetic valves are now used for the majority of surgical aortic valve replacements and for all transcatheter aortic valve replacements. However, bioprostheses are subject to structural valve deterioration (SVD) and have, therefore limited durability.

RECENT FINDINGS

Clinical, imaging, and circulating biomarkers may help to predict or indicate the presence of bioprosthetic valve SVD. The most important biomarkers of SVD includes: patient-related clinical biomarkers, such as diabetes and renal failure; valve-related biomarkers, such as absence of antimineralization process and severe prosthesis-patient mismatch; imaging biomarkers: the presence of valve leaflet mineralization on multidetector computed tomography or sodium fluoride uptake on positron emission tomography; and circulating biomarkers including: increased levels of HOMA index, ApoB/ApoA-I ratio, PCSK9, Lp-PLA2, phosphocalcic product. The assessment of these biomarkers may help to enhance risk stratification for SVD following AVR and may contribute to open novel pharmacotherapeutic avenues for the prevention of SVD.

SUMMARY

SVD may affect all bioprostheses after aortic valve replacement, and is the main cause of bioprosthetic valve failure and reintervention during the follow-up. Comprehensive assessment of clinical, imaging, and circulating biomarkers associated with earlier SVD could help strengthen the follow-up in high-risk patients and provide novel pharmacologic therapeutic strategies.

Postimplant biological aortic prosthesis degeneration: challenges in transcatheter valve implants

Surgical aortic valve replacement (SAVR) is highly effective and can be achieved with relatively low risk in patients with severe aortic stenosis. Bioprostheses have been used most frequently during the past 60 years. However, the function of biological valves usually declines after 10-15 years from implant when structural valve degeneration occurs often mandating a reoperation once valve dysfunction becomes haemodynamically significant. Known for many years by surgeons and cardiologists taking care of patients with SAVR, the issue of postimplant structural valve degeneration has been recently highlighted also in patients with transcatheter aortic valve implant (TAVI). There is growing concern that TAVI valves exhibit structural valve degeneration due to inherent challenges of the deployment mode. The impact on postimplant degeneration of TAVI valves compared to SAVR has still to be understood and defined. Based on the ongoing process of expanding TAVI indications, several potential shortcomings and caveats, learned during the last 60 years of SAVR experience, should be taken into consideration to refine this technique.

Long-Term Outcomes After Transcatheter Aortic Valve-in-Valve Replacement

BACKGROUND

Data on long-term outcomes after valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) are scarce. The objective of this study was to determine the long-term clinical outcomes and structural valve degeneration (SVD) over time in patients undergoing ViV-TAVR.

METHODS AND RESULTS

Consecutive patients undergoing ViV-TAVR in 9 centers between 2009 and 2015 were included. Patients were followed yearly, and clinical and echocardiography data were collected prospectively. SVD was defined as subclinical (increase >10 mm Hg in mean transvalvular gradient+decrease >0.3 cm² in valve area or new-onset mild or moderate aortic regurgitation) and clinically relevant (increase >20 mm Hg in mean transvalvular gradient+decrease >0.6 cm² in valve area or new-onset moderate-to-severe aortic regurgitation). A total of 116 patients (mean age, 76±11 years; 64.7% male; mean Society of Thoracic Surgeons score, 8.0±5.1%) were included. Balloon- and self-expandable valves were used in 47.9% and 52.1% of patients, respectively, and 30-day mortality was 6.9%. At a median follow-up of 3 years (range, 2-7 years), 30 patients (25.9%) had died, 20 of them (17.2%) from cardiovascular causes. Average mean transvalvular gradients remained stable up to 5-year follow-up ( P=0.92), but clinically relevant SVD occurred in 3/99 patients (3.0%), and 15/99 patients (15.1%) had subclinical SVD. One patient with SVD had redo ViV-TAVR.

CONCLUSIONS

About one-fourth of ViV-TAVR recipients had died after a median follow-up of 3 years. Overall valve hemodynamics remained stable over time and clinically relevant SVD was infrequent, but 1 out of 10 patients exhibited some degree of SVD.

Valve-in-Valve TAVR: State-of-the-Art Review

An increasing number of surgically implanted bioprostheses will require re-intervention for structural valve deterioration. Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has become an alternative to reoperative surgery, currently approved for high-risk and inoperable patients. Challenges to the technique include higher rates of prosthesis–patient mismatch and coronary obstruction, compared to native valve TAVR. Herein, we review results of ViV TAVR and novel techniques to overcome the aforementioned challenges.

Editor-in-Chief's Top Picks From 2018

Each week, I record audio summaries for every article in JACC, as well as an issue summary. Although this process is quite time-consuming, I have become familiar with every paper that we publish. Thus, I have personally selected the top 100 papers (both Original Investigations and Review Articles) from 15 distinct specialties each year. In addition to my personal choices, I have included papers that have been the most accessed or downloaded on our websites, as well as those selected by the JACC Editorial Board members. In order to present the full breadth of this important research in a consumable fashion, we will present these abstracts in this issue of JACC. The highlights comprise the following sections: Basic & Translational Research, Cardiac Failure, Cardiomyopathies/Myocardial & Pericardial Diseases, Cardio-oncology, Congenital Heart Disease, Coronary Disease & Interventions, CVD Prevention & Health Promotion, CV Medicine & Society, Hypertension, Imaging, Metabolic & Lipid Disorders, Rhythm Disorders, Valvular Heart Disease, and Vascular Medicine (1-100).

Valve durability after transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure to treat severe symptomatic aortic stenosis. While the TAVI procedure can be performed safely and provide excellent 5-year results, little is known about long-term durability. TAVI valves are composed of bioprosthetic leaflets are prone to deterioration, which are categorized as structural valve deterioration (SVD) and non-SVD. SVD refers to an intrinsic pathology of the leaflets or stent structure with mechanisms that include leaflet calcification, leaflet tear, stent fracture, or stent creep. Non-SVD processes include valve thrombosis, infective endocarditis and patient prosthesis mismatch. TAVI valves degenerate by similar mechanisms as bioprosthetic surgical aortic valves. Unique mechanisms that contribute to TAVI degeneration include valve crimpling, balloon expansion, stent under-expansion and valve thrombosis. The absence of a universally accepted definition of SVD poses a challenge in estimating valve durability. Traditional surgical bioprosthetic aortic valves have demonstrated excellent durability with clinically relevant SVD of 6.6% at 10-year follow up. Long-term durability of TAVI valves, however, remain poorly defined. From meta-analysis TAVI trials, SVD was estimated at 7% at 5 years. With iterative improvements in TAVI valve construction and deployment techniques, long-term durability may improve. Until long-term outcomes are better understood, TAVI should be used with caution in younger patients.

A running suture line for aortic valve replacement does not increase the rate of postoperative complete heart block

BACKGROUND

Surgical implantation of a prosthetic aortic valve is typically done with multiple interrupted sutures. We adapted a running suture line technique for prostheses implantation to decrease the rate of complete heart block necessitating permanent pacemaker.

METHODS

374 patients undergoing isolated aortic valve replacements were identified between 2015 and 2017. Patients with preoperative heart block, patients undergoing concomitant MAZE procedure and those undergoing multivalve procedures were excluded. Interrupted technique was performed with multiple non-pledgeted sutures. Running technique was performed with three 2-0 polypropylene sutures. Propensity-score matching (caliper distance = 0.10) was used to match based on patient age, gender, BMI, diabetes mellitus, renal failure, heart failure, arrythmias, use of anti-arrhythmics, and STS PROM.

RESULTS

Propensity score matching yielded 103 pairs of running technique and interrupted technique patients for analysis. Within the propensity score-matched cohort, there were no differences in sustained complete heart block and need for pacemaker, 4 (3.8%) for running technique vs 3 (2.9%) for interrupted technique (p = 0.307). At 4 weeks, there was no difference in mean prosthetic aortic valve gradients calculated on transthoracic echocardiogram (6.39 ± 2.47 mmHg vs 6.46 ± 2.86, p = 0.850). There was no difference in paravalvular leak (0 (0%) vs 2 (1.9%), p = 0.070).

CONCLUSIONS

Surgical implantation of a prosthetic aortic valve may be performed with a running suture technique without any significant increase in risk of heart block, need for permanent pacemaker or paravalvular leak. Long-term data will be critical to evaluate any development of paravalvular leaks in the future.

Degeneration of prosthesis after transcatheter aortic valve implantation

With the expanding indication of transcatheter aortic valve implantation (TAVI) to younger, lower risk population, transcatheter aortic valve (TAV) long-term durability is becoming an emerging issue to face with. Recently, the standardization of structural valve deterioration (SVD) definition by a join committee of the European Association of Percutaneous Cardiovascular Interventions (EAPCI), the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) has permitted to evaluate for the first time the rates of TAV durability with comparable endpoint. A few studies reporting on structural valve dysfunction (SVD) after TAVI up to 8 years using these standardized criteria have found very low rates of valve deterioration, thus supporting the adoption of TAVI treatment even for younger patients. For patients showing SVD at follow-ups, the VIVID (Valve-in-Valve International Data) group recently proposed an algorithm for their management. Re-do TAVI seems to be a safer and valid alternative to re-do surgery for symptomatic patients. This article review will go through the current evidence of TAV durability, describing the types of failure and strategies of treatment.