Repeat Transcatheter Aortic Valve Replacement for Transcatheter Prosthesis Dysfunction

Coronary Risk in Transcatheter Aortic Valve Replacement, Overview of Data, Challenges, and Best Practices

Coronary artery obstruction is a rare complication of transcatheter aortic valve replacement (TAVR). This risk increases in TAVR-valve-in-valve procedure. Several anatomic risk factors were described in many studies to identify the predictive elements of coronary artery occlusion on computed tomography cardiac scan. Rescue percutaneous coronary intervention was the first approach described to treat this complication with a high mortality rate. Later on, preventive chimney stenting technique was evaluated and results showed that is a safe and effective strategy but it leads to a difficult coronary access later. New preventive techniques are being evaluated recently (Basilica and Shorctut).

Long-term results of transcatheter aortic valve replacement in degenerated surgical aortic valves-a propensity score matched analysis

BACKGROUND

The aim of this study was to analyse long-term valve function and all-cause mortality of patients undergoing transcatheter aortic valve replacement (TAVR) due to degenerated surgical aortic valve (SAV) bioprostheses.

METHODS

In this single-center study, all consecutive patients undergoing TAVR between December 2012 and December 2020 were included. Long-term echocardiographic results, functional status and 5-year all-cause mortality were analysed in patients with TAV-in-SAV and native valve TAVR in a propensity score matched analysis.

RESULTS

Out of 3423 patients who were eligible for the study, 136 experienced bioprosthetic valve dysfunction, whereas 3287 patients underwent native valve TAVR. After 2:1 propensity score matching, baseline characteristics without relation to prior SAVR were comparable between both groups. Regarding 5-year all-cause mortality, no difference was observed between patients with prior SAVR and native valve TAVR, in either unadjusted analysis, or after propensity score matching (corresponding hazard ratio: 0.95, 95% CI: 0.70-1.30, p = 0.75). In addition, while pressure gradients were higher in patients with TAV-in-SAV in long-term echocardiographic follow-up, moderate or severe hemodynamic valve deterioration did not occur more often in this group.

CONCLUSIONS

In this propensity score matched analysis, long-term all-cause mortality and echocardiographic valve function of patients with TAVR in prior bioprosthesis were comparable to patients with native valve TAVR.

Transcatheter aortic valve implantation versus surgery in low-risk patients: in-hospital and mid-term outcomes

OBJECTIVES

The aim of our study is to compare post-procedural outcomes and mid-term mortality of low-risk patients treated by transfemoral TAVI or surgical aortic valve replacement (AVR) for severe aortic stenosis.

METHODS

Data of consecutive patients undergoing AVR or TAVI from September 2017 to December 2021 were prospectively collected and retrospectively reviewed. Eligible patients were aged between 75 and 85 years with low-surgical risk and isolated severe aortic stenosis. Exclusion criteria were prior heart surgery, valve-in-valve procedure and the need for concomitant procedures. The primary end-point was mid-term all-cause mortality.

RESULTS

Three hundred fifty-one patients were enrolled. Of these, 243 underwent TAVI and 108 underwent AVR. Compared to AVR, TAVI patients were older (82 [78-83 ] vs 78 [77-80], P < 0.001), with higher incidence of advanced chronic kidney disease (33.3% vs 15.7%, P < 0.001) and poor mobility (15.6% vs 5.6%, P = 0.008) and a higher Euroscore II (2.2 [1.72-2.98] vs 1.9 [1.31-2.46 ], P = 0.002). AVR patients had a higher incidence of post-procedural AKI (29.6% vs 4.5%, P < 0.001), while TAVI patients had a higher incidence of LBBB (23.9% vs 1.8%, P < 0.001) and at least mild to moderate PVL (4.5% vs 0%, P = 0.021). Mid-term mortality was higher among TAVI patients (HR 0.38 [95% CI 0.23-0.88], P = 0.020). In the matched cohort, TAVI had a higher incidence of LBBB (11.5% vs 1.3%, P = 0.018) and permanent PM implantation (12.8% vs 5.1%, P = 0.041), while AVR patients had a higher incidence of post-procedural AKI (33.3% vs 5.1%, P < 0.001). Mid-term mortality was higher in TAVI patients (HR 0.36 [95% CI 0.21-0.87], P = 0.019).

CONCLUSIONS

TAVI patients demonstrated a higher mid-term mortality and a higher incidence of post-procedural conduction abnormalities and PVL which remain a concern in low-risk patients.

A New Benchmark for Modern Management of Valvular Heart Disease: The Whole-Life Cycle Management System

Valvular heart disease (VHD) is rapidly increasing in prevalence worldwide, affecting millions and significantly impacting global health care systems. Despite notable advancements in understanding VHD progression, perioperative management, imaging techniques, and transcatheter therapies over the past 2 decades, the condition has not received the attention it deserves from the public and policymakers. Many patients with VHD in low- and middle-income countries continue to experience low detection, intervention, and follow-up rates. Systematic care for elderly patients and those with severe comorbidities, as well as postoperative patients, remains insufficient, leading to higher mortality and morbidity rates. This review focuses on the deficiencies in VHD treatment within the Chinese health care system and discusses the modern management program, known as the whole-life cycle management system, that has been implemented to enhance the survival prognosis of VHD patients.

Redo-Transcatheter Aortic Valve Replacement Procedural Optimization and Patient Selection: From Bench to Clinical Practice

With recent guidelines expanding transcatheter aortic valve replacement (TAVR) to younger patients, indications for redo-TAVR will also likely increase. When compared with TAVR, redo-TAVR is a rare and novel procedure. Current clinical data derived from registries suggest excellent safety, with low rates of 30-day and 1-year mortality following redo-TAVR. Proper understanding of data from bench studies regarding optimal valve configurations, of patient anatomy and of the technical properties of transcatheter heart valves (THV) is essential for patient selection and procedural success. Lifetime management of redo-TAVR should start before the index procedure, as the choice of the index THV has a major impact on the feasibility of redo-TAVR. Procedural optimization by adequate valve sizing, commissural alignment and adequate implant depth of both index and redo-THV are critical determinants of optimal hemodynamics for maximized valve longevity, as well as lifelong coronary access.

Precision medicine in the management of valvular heart disease

The management of valvular heart disease has undergone a remarkable transformation over the past two decades, which was driven by the advent of catheter-based treatment methods. Whereas medical therapy was the only available treatment option for many older patients deemed unsuitable for conventional surgery until the early 2000s, a wide range of interventional therapies is now available. Transcatheter aortic valve replacement and mitral valve transcatheter edge-to-edge repair evidently provide prognostic advantages over medical therapy for inoperable patients with severe aortic stenosis and secondary mitral regurgitation, and they have been demonstrated to be non-inferior to conventional surgery in certain operable patient groups. Although catheter-based therapies of aortic and tricuspid regurgitation have not yet been proven to provide prognostic benefits, these approaches enable substantial and sustainable improvements in symptoms as well as quality of life while demonstrating a favorable safety profile. Given the multitude of available options for the treatment of valvular heart diseases, determining the appropriate indication and selecting the optimal therapeutic approach often pose significant challenges. This review article highlights the latest advancements in valvular heart disease management and explores the patient-centered application of available therapies within the framework of an approach toward precision medicine.

Platform Selection for Patients Undergoing Transcatheter Aortic Valve Replacement: A Practical Approach

Transfemoral transcatheter aortic valve Replacement (TAVR) has become the standard therapy for patients with severe aortic stenosis in patients over 75 years old in Europe or 65 years old in the United States, regardless of the surgical risk. Furthermore, iterations of existing transcatheter aortic valves (TAVs), as well as devices with novel concepts, have provided substantial improvements with respect to the limitations of previous-generation devices. Hence, treatment of a broader spectrum of patients has become feasible, and a sophisticated selection of the appropriate TAV tailored to patients' anatomy and comorbidities is now possible. Anatomy, patient characteristics, and operator experience must all inform proper device selection. This review describes the features and performance of the current generation of TAVs with the aim of providing a practical approach for clinicians when selecting the appropriate TAV for a specific patient.

Transcatheter Aortic Valve Replacement Beyond Severe Aortic Stenosis: JACC State-of-the-Art Review

Transcatheter aortic valve replacement (TAVR) has become the preferred treatment option in appropriate patients with symptomatic severe aortic stenosis (AS). A number of advancements have since expanded the eligible population to bicuspid aortic valve with feasible anatomy; small aortic annuli; low-flow, low-gradient AS; and younger patients. Focus has also shifted beyond the symptomatic severe patients to asymptomatic severe and moderate AS, as early valve replacement may prevent irreversible cardiac remodeling. Dedicated devices to treat native aortic regurgitation have shown encouraging short-term outcomes. While the expansion of TAVR to younger patients has raised questions about valve durability and feasibility of reintervention, valve-in-valve TAVR has thus far shown encouraging midterm results. In this review, we summarize the evidence in these contemporary TAVR populations, exploring both the promise and challenge of broadening the patient pool for this minimally invasive procedure.

What Are the Implications of Choosing a TAVR-First Strategy in the Lifetime Management of Aortic Stenosis?: A Critical Review of TAVR-Explant- and Redo-TAVR

Some patients with aortic stenosis may require multiple valve interventions in their lifetime, and choosing transcatheter aortic valve replacement (TAVR) as the initial intervention may be appealing to many. If their transcatheter heart valve degenerates later in life, most will hope to undergo redo-TAVR. However, if redo-TAVR is not feasible, some may have to undergo surgical explantation of their transcatheter heart valve (TAVR-explant). With rising numbers of TAVR in younger patients, we address the practical implications of choosing a TAVR-first strategy. In this review we explore potential factors contributing to higher-than-expected mortality after TAVR-explant, synthesize available outcomes data for TAVR-explant for structurally degenerated valves, and describe strategies to standardize and optimize surgical techniques for TAVR-explant. We also discuss clinical outcomes of redo-TAVR within the context of limitations in currently published series and highlight the potential benefit of virtual planning to assess the feasibility of future redo-TAVR before implanting the first valve. Finally, we highlight areas for future investigation to inform management strategies in patients who may require multiple aortic valve interventions.

Clinical Characteristics and Outcomes of Patients Undergoing 3 Aortic Valve Interventions: The THIRD Multicenter Registry

BACKGROUND

Lifetime treatment of aortic valve disease is a matter of increasing debate. Although the risks of a second aortic valve intervention are recognized, little attention has been given to the challenges of a third.

OBJECTIVES

This study delves into the clinical characteristics, indications, and outcomes of patients undergoing 3 aortic valve interventions.

METHODS

The THIRD (THree aortIc Reinterventions for valve Disease) registry is a retrospective multicenter, international study of patients who underwent a third procedure on the aortic valve, either surgically or transcatheter-based. Patients undergoing 2 aortic procedures during the same hospital admission were excluded. Baseline characteristics, timing, and mode of bioprosthetic failure, sequence of the procedures, and clinical outcomes were adjudicated according to the Valve Academic Research Consortium criteria.

RESULTS

A total of 51 patients from 11 centers were enrolled in this study. Median follow-up time was 565 (314-1,560) days. Eighteen patients (35%) underwent surgical aortic valve replacement (SAVR), and 33 of 51 patients (65%) underwent transcatheter aortic valve replacement (TAVR) as the third intervention. Mean age was 69 ± 14 years, 20 of 51 patients (39%) were female. STS score was 5.0% (Q1-Q3: 3.3%-7.0%). In all TAVR cases, the indication for the first intervention was severe aortic stenosis, as was the indication in 31 of 45 (69%) of SAVR cases (33% bicuspid). The most prevalent procedure sequence was SAVR-SAVR-TAVR (19/51, 37%), followed by SAVR-SAVR-SAVR (10/51, 20%) and SAVR-TAVR-TAVR (10/51, 20%). TAVR-TAVR-TAVR was performed in 4 of 51 cases (8%). The primary indications for a third intervention included structural valve deterioration (SVD) (39/51, 76%), non-SVD (8/51, 16%), and endocarditis (2/51, 4%). Excluding patients with a mechanical prosthesis, predictors of SAVR as third intervention included a lower STS score (OR: 0.58; 95% CI: 0.34-0.98; P = 0.04) and the presence of moderate or severe prosthesis-patient mismatch (OR: 44.8; 95% CI: 2.41-122.00; P = 0.01). Thirty-day device success was 85% for TAVR and 94% for SAVR.

CONCLUSIONS

In the THIRD registry, SVD emerged as the predominant indication for a third aortic valve procedure. The most frequent procedure sequence was SAVR-SAVR-TAVR, whereas TAVR-TAVR-TAVR was less common. Although the short-term outcomes in our selected cohort were favorable, further investigation is needed.

Acute Decompensated Valvular Disease in the Intensive Care Unit

Acute decompensated valvular disease encompasses a group of complex and challenging conditions, which are often the primary reason for admission to the cardiac intensive care unit and can also complicate the management of other primary cardiac disorders. Critically ill patients with valvular disease also present unique diagnostic and management challenges. Historically, medical and percutaneous interventional therapies have been limited and surgery was the only definitive treatment; however, surgical risk can at times be prohibitive. High-quality evidence to direct management of acute valvular disorders in this population is lacking and societal guidelines largely do not address treatment options for critically ill patients with decompensated valvular disease. In this review, we discuss the clinical presentation and epidemiology of commonly encountered valvular diseases in the modern cardiac intensive care unit, highlight key pathophysiology, detail gaps in evidence, describe the pivotal role of multidisciplinary Heart Teams, and provide guidance for management.

Balloon aortic valvuloplasty with simultaneous aortic root injection: a case report of an adjunctive strategy to computed tomography for predicting coronary obstruction in transcatheter aortic valve-in-transcatheter aortic valve procedures

Background

Computed tomography (CT) assessment is the standard for predicting coronary obstruction (CO) caused by sinus sequestration (SS) during transcatheter aortic valve (TAV) implantation in degenerated TAV (TAV-in-TAV) procedure, but it may not always be accurate. This report describes a prediction method for CO by using balloon aortic valvuloplasty (BAV) during TAV-in-TAV.

Case summary

An 87-year-old woman with a history of balloon-expandable transcatheter heart valve (BE-THV) implantation 7 years prior was admitted with worsening dyspnoea. Echocardiography revealed severe THV deterioration, and CT confirmed calcium proliferation in the THV. Our heart team decided to perform a TAV-in-TAV procedure using a 23-mm BE-THV. Preoperative CT imaging indicated an intermediate risk of CO. To evaluate CO risk more precisely, the top of a 20-mm balloon was positioned near the top of a BE-THV stent and inflated, followed by simultaneous aortic root injection (SARI). During SARI, contrast flowed into both coronary arteries, predicting a low risk of CO. Based on these findings, TAV-in-TAV was performed without coronary protection. The procedure was completed successfully without CO. After the procedure, the patient's symptoms improved, and echocardiography showed normal valve function. She was discharged without complications and remains under outpatient follow-up care.

Discussion

The diagnostic method for predicting CO using BAV with SARI could serve as a valuable adjunctive diagnostic tool in patients with an intermediate or high risk of SS anatomy after TAV-in-TAV. In such cases, this method may provide additional insights concerning precise CO risk and the indication of leaflet modification technique during TAV-in-TAV.

Redo-TAVI with the SAPIEN 3 valve in degenerated calcified CoreValve/Evolut explants

BACKGROUND

Redo-transcatheter aortic valve implantation (TAVI) is the treatment of choice for failed transcatheter aortic valves. Currently, implantation of a SAPIEN 3 (S3) is indicated for redo-TAVI in degenerated CoreValve/Evolut (CV/EV) transcatheter aortic valves (TAVs) but is not well understood.

AIMS

We aimed to evaluate S3 function following implantation in explanted calcified CV/EV TAVs and to assess the impact of CV/EV pathology on redo-TAVI outcomes.

METHODS

Ex vivo hydrodynamic testing was performed per the International Organization for Standardization (ISO) 5840-3 standard on 4 S3 TAVs implanted at node 5 in calcified CV/EV explants. The mean gradient (MG), effective orifice area (EOA), peak velocity, regurgitant fraction (RF), geometric orifice area (GOA), leaflet overhang, leaflet pinwheeling, neoskirt height, and frame deformation were evaluated.

RESULTS

CV/EV explants were calcified and stenotic. Following S3 implantation, the MG and peak velocity decreased. As per the ISO standard, all S3 implants showed adequate EOA, and 3 out of 4 had an RF within the accepted value (<20%). CV/EV leaflet overhang ranged from 25-37%. Calcified leaflets remained stationary throughout the cardiac cycle (difference <9%) and were not pinned in a manner that constrained S3 systolic flow or appeared to prevent selective frame cannulation. The downstream CV/EV GOA was larger than the upstream S3 GOA during systole. S3 frame underexpansion was seen, resulting in leaflet pinwheeling (range 13-30%). Above the neoskirt, calcium protrusion was observed in contact with the S3 leaflets.

CONCLUSIONS

S3 implantation at node 5 in calcified CV/EV valves resulted in satisfactory hydrodynamic performance in most configurations tested with stable leaflet overhang throughout the cardiac cycle. The long-term implications of S3 underexpansion, leaflet pinwheeling, and calcium protrusion require future studies.

Feasibility of redo-TAVI in the self-expanding ACURATE neo2 valve: a computed tomography study

BACKGROUND

Redo-transcatheter aortic valve implantation (TAVI) may be unfeasible because of the risk of compromising coronary flow or coronary access by the pinned back leaflets of the index transcatheter aortic valve.

AIMS

We aimed to evaluate the feasibility of redo-TAVI using the balloon-expandable SAPIEN 3 (S3) implanted within the self-expanding ACURATE neo2 (ACn2) valve and to identify predictors associated with a high risk of compromising coronary flow.

METHODS

A total of 153 post-ACn2 TAVI cardiac computed tomography scans were analysed. Redo-TAVI using an S3 was simulated in two positions: S3 outflow to the ACn2 upper crown (low implant) and S3 outflow to the base of the ACn2 commissural posts (high implant). The risk for coronary flow compromise and inaccessibility was determined by the height of the neoskirt created by the pinned back leaflets and the valve-to-aorta distances.

RESULTS

At a low S3 implant position, risk of coronary flow compromise was predicted in only 8% of patients and this increased to 60% with a high S3 position. In accordance, coronary access was predicted to be unrestricted in 52% versus 13% of patients with a low versus high S3 implantation. Female sex, a small aortic annular dimension and a sinotubular junction-to-aortic annulus mean diameter ratio <1.15 were independent predictors associated with a high risk for coronary flow compromise.

CONCLUSIONS

The feasibility of redo-TAVI with an S3 in an ACn2 depends on the implant depth of the S3 and the geometry of the surrounding aorta. A low S3 implant may reduce the risk of coronary flow compromise and inaccessibility.

Decision-Making Approach to the Treatment of Young and Low-Risk Patients With Aortic Stenosis

Over a decade of randomized controlled trial data demonstrate excellent outcomes with transcatheter aortic valve replacement or surgical aortic valve replacement for patients with symptomatic severe aortic stenosis regardless of surgical risk. The 2020 American College of Cardiology/American Heart Association guidelines recommend both options for low-risk AS patients aged 65 to 80 years. However, the fastest growing population of patients receiving transcatheter aortic valve replacement in the United States is <65 years old, with little data to support the practice. The American College of Cardiology's Cardiac Surgery Team Section Leadership and Interventional Cardiology Councils, a multidisciplinary collaboration of cardiologists and cardiac surgeons, sought to summarize the relevant data into a decision-making tool for heart valve teams. A literature review was completed, and guidelines, randomized controlled trials, and large observational studies were summarized into a pragmatic decision-making approach to treating young and low-risk patients with AS.

Who Lives Longer, the Valve or the Patient? The Dilemma of TAVI Durability and How to Optimize Patient Outcomes

Over the past few years, transcatheter aortic valve implantation (TAVI) imposed itself as the first-choice therapy for symptomatic aortic stenosis (AS) in elderly patients at surgical risk. There have been continuous technological advancements in the latest iterations of TAVI devices and implantation techniques, which have bolstered their adoption. Moreover, the favorable outcomes coming out from clinical trials represent an indisputable point of strength for TAVI. As indications for transcatheter therapies now include a low surgical risk and younger individuals, new challenges are emerging. In this context, the matter of prosthesis durability is noteworthy. Initial evidence is beginning to emerge from the studies in the field, but they are still limited and compromised by multiple biases. Additionally, the physiopathological mechanisms behind the valve's deterioration are nowadays somewhat clearer and classified. So, who outlasts who-the valve or the patient? This review aims to explore the available evidence surrounding this intriguing question, examining the various factors affecting prosthesis durability and discussing its potential implications for clinical management and current interventional practice.

Management of Surgical Transcatheter Aortic Valve Replacement (TAVR) Valve Explantation for Early Degeneration: A Case Report

Early degeneration of the bioprosthetic aortic valve after transcatheter aortic valve replacement (TAVR) requires aortic valve reintervention, especially in young patients. However, the management of aortic valve reintervention after TAVR is not established. In this case report, the authors report a young patient with an early degenerated TAVR valve who underwent TAVR valve explantation and surgical aortic valve replacement with a mechanical valve. Subsequently, the patient required a permanent pacemaker for a complete heart block. This case report provides one of the management options for early degeneration of the TAVR valve, including benefits and risks from TAVR valve explantation.

Redo surgical aortic valve replacement for bioprosthetic structural valve deterioration

OBJECTIVES

To compare isolated primary bioprosthetic surgical aortic valve replacement (SAVR) with isolated redo surgical aortic valve replacement (rSAVR) due to structural valve deterioration (SVD).

METHODS

Clinical data of consecutive patients who underwent primary isolated SAVR and isolated rSAVR due to SVD between 1 January 2011 and 31 December 2022, at Leipzig Heart Center were retrospectively compared with regard to the primary outcome of all-cause mortality or stroke during hospitalization. Secondary outcomes of interest included myocardial infarction, re-exploration for bleeding, and permanent pacemaker implantation.

RESULTS

A total of 2620 patients, 39.5% females, with a median EuroSCORE II of 1.7 [interquartile range (IQR) 1.1-2.7] were identified, of which rSAVR was performed in 174 patients (6.6%). Patients undergoing primary SAVR were older (69 vs 67 years of age, P = 0.001) and were less likely to have a history of prior stroke (0.9% vs 4.0%, P = 0.003). Although both all-cause death and death or stroke occurred less often following primary SAVR (0.5% vs 5.8%, and 2.2% vs 6.9%, respectively; P < 0.001), prior surgery was not associated with adverse clinical outcome in multivariable analysis. In a matched comparison of 322 patients, rates of death or stroke did not differ between groups (4.8% for both rSAVR and SAVR, P = 1.0).

CONCLUSIONS

Although redo surgery for SVD is associated with increased rates of early mortality and stroke by univariate analysis, much of this increased risk can be accounted for by comorbidities. Patients undergoing rSAVR on an elective basis can expect an outcome similar to that of primary SAVR.

Unmet needs and knowledge gaps in aortic stenosis: A position paper from the Heart Valve Council of the French Society of Cardiology

Nowadays, valvular heart disease remains a significant challenge among cardiovascular diseases, affecting millions of people worldwide and exerting substantial pressure on healthcare systems. Within the spectrum of valvular heart disease, aortic stenosis is the most common valvular lesion in developed countries. Despite notable advances in understanding its pathophysiological processes, improved cardiovascular imaging techniques and expanding therapeutic options in recent years, there are still unmet needs and knowledge gaps regarding aortic stenosis pathophysiology, severity assessment, management and decision-making strategy. This review, prepared on behalf of the Heart Valve Council of the French Society of Cardiology, describes these gaps and future research perspectives to improve the outcome of patients with aortic stenosis.

Transcatheter Aortic Valve Replacement is Ready for Most Low-risk Patients: A Systematic Review of the Literature

Transcatheter aortic valve replacement (TAVR) has undergone rapid expansion, emerging as a viable therapeutic option for low-risk patients in lieu of surgical aortic valve replacement. This paper aims to provide a review of the scientific evidence concerning TAVR in low-risk patients, encompassing both observational and clinical trial data. Furthermore, a substantial proportion of low-risk patients possesses a bicuspid aortic valve, necessitating careful examination of the pertinent anatomic and clinical considerations to TAVR that is highlighted in this review. Additionally, the review expands upon some of the unique challenges associated with alternate access in low-risk patients evaluated for TAVR. Last, this review outlines the pivotal role of a multidisciplinary heart team approach in the execution of all TAVR procedures and the authors' vision of 'minimalist TAVR' as a new era in low-risk TAVR.

Treatment of Transcatheter Aortic Valve Thrombosis: JACC Review Topic of the Week

Transcatheter aortic valve (TAV) thrombosis may manifest as subclinical leaflet thrombosis (SLT) and clinical valve thrombosis. SLT is relatively common (10%-20%) after transcatheter aortic valve replacement, but clinical implications are uncertain. Clinical valve thrombosis is rare (1.2%) and associated with bioprosthetic valve failure, neurologic or thromboembolic events, heart failure, and death. Treatment for TAV thrombosis has been understudied. In principle, anticoagulation may prevent TAV thrombosis. Non-vitamin K oral anticoagulants, as compared to antiplatelet therapy, are associated with reduced incidence of SLT, although at the cost of higher bleeding and all-cause mortality risk. We present an overview of existing literature for management of TAV thrombosis and propose a rational treatment algorithm. Vitamin K antagonists or non-vitamin K oral anticoagulants are the cornerstone of antithrombotic treatment. In therapy-resistant or clinically unstable patients, ultraslow, low-dose infusion of thrombolytics seems effective and safe and may be preferred over redo-transcatheter aortic valve replacement or explant surgery.

Coronary Risk in Transcatheter Aortic Valve Replacement, Overview of Data, Challenges, and Best Practices

Coronary artery obstruction is a rare complication of transcatheter aortic valve replacement (TAVR). This risk increases in TAVR-valve-in-valve procedure. Several anatomic risk factors were described in many studies to identify the predictive elements of coronary artery occlusion on computed tomography cardiac scan. Rescue percutaneous coronary intervention was the first approach described to treat this complication with a high mortality rate. Later on, preventive chimney stenting technique was evaluated and results showed that is a safe and effective strategy but it leads to a difficult coronary access later. New preventive techniques are being evaluated recently (Basilica and Shorctut).

Durability of transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) is now utilised as a less invasive alternative to surgical aortic valve replacement (SAVR) across the whole spectrum of surgical risk. Long-term durability of the bioprosthetic valves has become a key goal of TAVI as this procedure is now considered for younger and lower-risk populations. The purpose of this article is to present a state-of-the-art overview on the definition, aetiology, risk factors, mechanisms, diagnosis, clinical impact, and management of bioprosthetic valve dysfunction (BVD) and failure (BVF) following TAVI with a comparative perspective versus SAVR. Structural valve deterioration (SVD) is the main factor limiting the durability of the bioprosthetic valves used for TAVI or SAVR, but non-structural BVD, such as prosthesis-patient mismatch and paravalvular regurgitation, as well as valve thrombosis or endocarditis may also lead to BVF. The incidence of BVF related to SVD or other causes is low (<5%) at midterm (5- to 8-year) follow-up and compares favourably with that of SAVR. The long-term follow-up data of randomised trials conducted with the first generations of transcatheter heart valves also suggest similar valve durability in TAVI versus SAVR at 10 years, but these trials suffer from major survivorship bias, and the long-term durability of TAVI will need to be confirmed by the analysis of the low-risk TAVI versus SAVR trials at 10 years.

Coronary Artery Obstruction After Transcatheter Aortic Valve Implantation: Past, Present, and Future

Coronary obstruction (CO) is a rare but critical complication of transcatheter aortic valve implantation. It is associated with significant morbidity and mortality. This comprehensive review elucidates the evolving landscape of CO risk assessment and management strategies in the contemporary era of transcatheter aortic valve implantation. Drawing upon recent advances in computed tomography angiography, we delve into the nuanced evaluation of anatomic parameters crucial for predicting CO risk. Furthermore, this review explores the utility of interventional and surgical techniques, including chimney stenting and leaflet modification systems, in mitigating CO complications. In summary, this review serves as a practical guide for clinicians navigating the complexities of CO prevention and management in the evolving landscape of transcatheter aortic valve implantation, with the goal of optimizing patient outcomes and ensuring procedural success.

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.

Reinterventions After CoreValve/Evolut Transcatheter or Surgical Aortic Valve Replacement for Treatment of Severe Aortic Stenosis

BACKGROUND

Data on valve reintervention after transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR) are limited.

OBJECTIVES

The authors compared the 5-year incidence of valve reintervention after self-expanding CoreValve/Evolut TAVR vs SAVR.

METHODS

Pooled data from CoreValve and Evolut R/PRO (Medtronic) randomized trials and single-arm studies encompassed 5,925 TAVR (4,478 CoreValve and 1,447 Evolut R/PRO) and 1,832 SAVR patients. Reinterventions were categorized by indication, timing, and treatment. The cumulative incidence of reintervention was compared between TAVR vs SAVR, Evolut vs CoreValve, and Evolut vs SAVR.

RESULTS

There were 99 reinterventions (80 TAVR and 19 SAVR). The cumulative incidence of reintervention through 5 years was higher with TAVR vs SAVR (2.2% vs 1.5%; P = 0.017), with differences observed early (≤1 year; adjusted subdistribution HR: 3.50; 95% CI: 1.53-8.02) but not from >1 to 5 years (adjusted subdistribution HR: 1.05; 95% CI: 0.48-2.28). The most common reason for reintervention was paravalvular regurgitation after TAVR and endocarditis after SAVR. Evolut had a significantly lower incidence of reintervention than CoreValve (0.9% vs 1.6%; P = 0.006) at 5 years with differences observed early (adjusted subdistribution HR: 0.30; 95% CI: 0.12-0.73) but not from >1 to 5 years (adjusted subdistribution HR: 0.61; 95% CI: 0.21-1.74). The 5-year incidence of reintervention was similar for Evolut vs SAVR (0.9% vs 1.5%; P = 0.41).

CONCLUSIONS

A low incidence of reintervention was observed for CoreValve/Evolut R/PRO and SAVR through 5 years. Reintervention occurred most often at ≤1 year for TAVR and >1 year for SAVR. Most early reinterventions were with the first-generation CoreValve and managed percutaneously. Reinterventions were more common following CoreValve TAVR compared with Evolut TAVR or SAVR.

Valvular heart disease: from mechanisms to management

Valvular heart disease is common and its prevalence is rapidly increasing worldwide. Effective medical therapies are insufficient and treatment was historically limited to the surgical techniques of valve repair or replacement, resulting in systematic underprovision of care to older patients and those with substantial comorbidities, frailty, or left ventricular dysfunction. Advances in imaging and surgical techniques over the past 20 years have transformed the management of valvular heart disease. Better understanding of the mechanisms and causes of disease and an increasingly extensive and robust evidence base provide a platform for the delivery of individualised treatment by multidisciplinary heart teams working within networks of diagnostic facilities and specialist heart valve centres. In this Series paper, we aim to provide an overview of the current and future management of valvular heart disease and propose treatment approaches based on an understanding of the underlying pathophysiology and the application of multidisciplinary treatment strategies to individual patients.

[Coronary obstruction following transcatheter aortic valve replacement. Risk evaluation and preventive strategies]

Coronary obstruction (CO) is a rare but potentially fatal complication of transcatheter aortic valve implantation (TAVI). The present article aims to summarize the evidence on CO risk factors and provide an overview of preventive strategies. We performed a comprehensive literature review focused on these items. The analysis included studies addressing patient-specific characteristics, procedural aspects, and the effectiveness of various prevention techniques in mitigating CO risk. Specific risk factors for CO, which can be assessed by evaluating patient characteristics using computed tomography, are described. Procedural factors associated with an increased risk of CO are discussed. Preventive techniques, including the chimney stent and bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA), are also described, highlighting the advantages and disadvantages of each method. The present review also provides an overview of emerging dedicated devices designed to address this complication. In conclusion, identifying patients at risk for CO is crucial for optimizing TAVI outcomes. Comprehensive imaging assessment and appropriate preventive strategies, such as the BASILICA technique, can mitigate the risk of CO and improve patient outcomes. Further research is needed to validate emerging dedicated devices.

TAVR-in-TAVR with a balloon-expandable valve for paravalvular leak

Introduction

Paravalvular leak (PVL) is a severe complication of transcatheter aortic valve replacement (TAVR) that can lead to poor outcomes. TAVR-in-TAVR is a promising treatment for PVL; however, reports on its safety or efficacy are limited. In this study, we aimed to investigate the clinical outcomes of TAVR-in-TAVR using balloon-expandable prostheses for PVLs after TAVR.

Methods

We retrospectively analyzed data from patients who underwent TAVR-in-TAVR using balloon-expandable Sapien prostheses for PVL after an initial TAVR at our institution. The procedural success, in-hospital complications, all-cause mortality, and echocardiographic data for up to 2 years post-surgery were evaluated.

Results

In total, 31 patients with a mean age of 81.1 ± 7.9 years and mean Society of Thoracic Surgeons score of 8.8 ± 5.4% were identified. The procedural success rate of TAVR-in-TAVR was 96.8% (30/31). No in-hospital deaths, cardiac tamponade, or conversion to sternotomy occurred. Re-intervention was performed in only one patient (3.2%) during hospitalization. The all-cause mortality rates at 30 days and 2 years were 0% and 16.1%, respectively. A significant reduction in the PVL rate was observed at 30 days compared with that at baseline (p < 0.01).

Discussion

Our findings suggest that TAVR-in-TAVR using balloon-expandable prostheses is safe and effective for PVL after TAVR with low complication rates and acceptable long-term outcomes. Further studies with larger sample sizes are needed to confirm our findings.

Valve Type and Operative Risks in Surgical Explantation of Transcatheter Aortic Valves: A Systematic Review and Meta-Analysis

Indication to perform surgical explantation of TAVR is becoming increasingly more frequent, due to the higher number of transcatheter procedures performed in patients with longer life expectancy. We proposed to perform a systematic review and meta-analysis with metaregression to identify potential factors that can determine an increase in the high mortality and morbidity that characterize these surgical procedures. MEDLINE and Embase were searched for relevant studies. Twelve studies were eligible according to our inclusion criteria. TAVR explantation was confirmed as a procedure with high 30-day mortality (0.17; 95% CI, 0.14-0.21) and morbidity (stroke incidence 5%; 95% CI, 0.04-0.07; kidney injury incidence 16%; 95% CI, 0.11-0.24). The type of transcatheter valve implanted during the index procedure did not influence the outcomes after surgical explantation. The role of these high-risk operations is growing, and it will likely expand in the coming years. Specific tools for risk stratification are required.

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.

Lifetime Management of Patients With Severe Aortic Stenosis in the Era of Transcatheter Aortic Valve Replacement

Aortic stenosis is the most common valvular disease. Surgical aortic valve replacement (SAVR) using mechanical valves has been the preferred treatment for younger patients, but bioprosthetic valves are gaining favour to avoid anticoagulation with warfarin. Transcatheter aortic valve replacement (TAVR) was approved in recent years for the treatment of severe aortic stenosis in intermediate- and low-risk patients as an alternative to SAVR. The longer life expectancy of these groups of patients might exceed the durability of the TAVR or SAVR bioprosthetic valves. Therefore, many patients need 2 or even 3 interventions during their lifetime. Because it has important implications on the feasibility of subsequent procedures, the decision between opting for SAVR or TAVR as the primary procedure requires thorough consideration by the heart team, incorporating patient preferences, clinical indicators, and anatomic aspects. If TAVR is favoured initially, selecting the valve type and determining the implantation level should be conducted, aiming for positive outcomes in the index intervention and keeping in mind the potential for subsequent TAVR-in-TAVR procedures. When SAVR is selected as the primary procedure, the operator must make choices regarding the valve type and the potential need for aortic root enlargement, with the intention of facilitating future valve-in-valve interventions. This narrative review examines the existing evidence concerning the lifelong management of severe aortic stenosis, delving into available treatment strategies, particularly emphasising the initial procedure's selection and its impact on subsequent interventions.

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.

Comparison of Mid-Term Prognosis in Intermediate-to-Low-Risk Contemporary Population with Guidelines-Oriented Age Cutoff

BACKGROUND

Current European guidelines support transcatheter aortic valve implantation (TAVI) in intermediate-to-low-risk patients ≥75 years-old, but its prognostic relevance is unknown.

METHODS

Intermediate-to-low-risk (The Society of Thoracic Surgeons score <8%) patients enrolled in the HORSE registry were included. We compared the populations aged under 75 with those over 75. The primary endpoint was all-cause mortality.

RESULTS

A total of 2685 patients were included: 280 (8.6%) < 75 and 2405 ≥ 75 years. Through a mean follow-up of 437 ± 381 days, 198 (8.2%) and 23 (8.2%) patients died in the two arms without statistically significant differences (log-rank p = 0.925). At Cox regression analysis, age did not predict the occurrence of all-cause death, neither as a continuous variable (HR 1.01, 95% CI 0.99-1.04, p = 0.294) nor dichotomizing according to the prespecified cutoff of 75 years (HR 0.97, 95% CI 0.63-1.51, p = 0.924). Time-to-event ROC curves showed low accuracy of age to predict all-cause mortality (area under the curve of 0.54 for both 1-year and 2-year outcomes).

CONCLUSIONS

TAVI has comparable benefits across age strata for intermediate-to-low-risk patients. The age cutoff suggested by the current guidelines is not predictive of the risk of adverse events during hospital stays or of all-cause mortality through a mid-term follow-up.

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.

Assessing Potential Risks of Future Redo Transcatheter Aortic Valve Replacement in Asian Patients

Background

In the Asian cohort, data are limited on the risk for coronary obstruction due to sinus of Valsalva (SOV) sequestration in redo transcatheter aortic valve replacement (TAVR) procedures.

Objectives

The aim of this study was to assess the potential risk for coronary obstruction in simulated redo TAVR in Asian patients.

Methods

Post-TAVR computed tomographic data from 788 patients who received balloon-expandable (BE) SAPIEN 3 transcatheter aortic valves (TAVs) and 334 patients who received self-expanding (SE) Evolut R or Evolut PRO TAVs were analyzed. The risk for coronary obstruction due to SOV sequestration in redo TAVR, defined as the TAV commissure level above the sinotubular junction (STJ) and a TAV-to-STJ distance <2.0 mm in each coronary sinus, was retrospectively evaluated.

Results

The potential risks for coronary obstruction due to SOV sequestration at 1 or both coronary arteries were identified in 52.1% of the BE TAV group and 71.3% of the SE TAV group (P < 0.001). After adjusting for multiple covariates, STJ diameter, STJ height, TAV oversizing degree by area, and implantation depth were independently associated with SOV sequestration risk in the BE TAV group, whereas STJ diameter and implantation depth were independently associated with SOV sequestration risk in the SE TAV group.

Conclusions

Coronary obstruction due to SOV sequestration in redo TAVR may occur in a substantial number of Asian patients. This finding suggests the importance of considering the structural feasibility of future redo TAVR when implanting the first TAV, especially in Asian patients with long life expectancy.

Early offering transcatheter aortic valve replacement to patients with moderate aortic stenosis: quantifying costs and benefits - a Markov model-based simulation study

OBJECTIVE

Aortic stenosis (AS) is one of the most common acquired cardiac valvular diseases. The success of transcatheter aortic valve implantation (TAVI) for severe AS has led to increasing interest in its use to earlier disease-moderate AS (MAS).

DESIGN

Model-based study using a Markov microsimulation technique to evaluate the long-term costs and benefits associated with 'early' TAVI. Key data inputs were sourced from the international literature and costs were obtained from Australian sources.

SETTING

Australian health care system perspective.

PARTICIPANTS

10 000 hypothetical MAS patients with or without left ventricular diastolic dysfunction or impaired left ventricular ejection fraction.

INTERVENTION

Comparing early TAVI to medical management over a life time horizon for MAS patients aged >65 years. We evaluated the cost-effectiveness of offering early TAVI in five scenarios (10%, 25%, 50%, 75% and 90% take-up rates).

PRIMARY AND SECONDARY OUTCOME MEASURES

The primary outcome measure is quality-adjusted life years (QALY) gained and the incremental cost-utility ratio (ICUR). Secondary outcomes are life-years gained and the number of heart failure case avoided.

RESULTS

Offering early TAVI for MAS patients resulted in both higher healthcare costs and greater benefits (an increase of 3.02 QALYs or 3.99 life-years) per person treated. The ICUR was around $A10 867 and $A11 926 per QALY gained for all five scenarios, with the total cost of early TAVI to the healthcare system being anticipated to be up to $A3.66 billion. Sensitivity analyses indicated a 100% probability of being cost-effective with a willingness to pay threshold of $A50 000/QALY. The benefits remained, even with assumptions of high levels of repeat valve replacement after TAVI.

CONCLUSION

While ongoing randomised controlled trials will define the benefit of TAVI to MAS patients, these results suggest that this intervention is likely to be cost-effective.

Bioprosthetic Valves for Lifetime Management of Aortic Stenosis: Pearls and Pitfalls

This review explores the use of bioprosthetic valves for the lifetime management of patients with aortic stenosis, considering recent advancements in surgical (SAV) and transcatheter bioprostheses (TAV). We examine the strengths and challenges of each approach and their long-term implications. We highlight differences among surgical bioprostheses regarding durability and consider novel surgical valves such as the Inspiris Resilia, Intuity rapid deployment, and Perceval sutureless bioprostheses. The impact of hemodynamics on the performance and durability of these prostheses is discussed, as well as the benefits and considerations of aortic root enlargement during Surgical Aortic Valve Replacement (SAVR). Alternative surgical methods like the Ross procedure and the Ozaki technique are also considered. Addressing bioprosthesis failure, we compare TAV-in-SAV with redo SAVR. Challenges with TAVR, such as TAV explantation and considerations for coronary circulation, are outlined. Finally, we explore the potential challenges and limitations of several clinical strategies, including the TAVR-first approach, in the context of aortic stenosis lifetime management. This concise review provides a snapshot of the current landscape in aortic bioprostheses for physicians and surgeons.

Surgical Explantation of Failed Transcatheter Aortic Valve Replacement

BACKGROUND

Recent reports have demonstrated worse than expected outcomes of surgical explantation after transcatheter aortic valve replacement (TAVR). However in-depth analysis of the short- and mid-term risk of concomitant cardiac surgery at the time of TAVR explant is lacking.

METHODS

Data from the multicenter EXPLANT-TAVR registry of patients undergoing TAVR-explant between November 2009 and September 2020 were retrospectively analyzed. Patients undergoing concomitant procedures were included, but explants performed during the same admission as the initial TAVR or concomitant procedures performed on the aortic root, ascending aorta, or arch were excluded. Outcomes were evaluated between the isolated surgical aortic valve replacement (SAVR) and concomitant SAVR groups. Median follow-up was 6.6 months.

RESULTS

Among 199 patients, concomitant SAVR was performed in 94 patients (47.2%), primarily with mitral valve surgery (n = 45) followed by coronary artery bypass grafting (n = 23). Despite similar mean ages between groups (72.8 vs 73.4 years), concomitant SAVR had a higher median Society of Thoracic Surgeons Predicted Risk of Mortality score at the index TAVR (5.9% vs 3.7%, P = .001). There were no differences in median time-to-explant between groups (12.9 vs 8.7 months, P = .78). However concomitant SAVR had longer mean cardiopulmonary bypass (166 vs 114 minutes, P = .001) and cross-clamp times (123 vs 81 minutes, P = .001). Both 30-day (16.7% vs 9.9%) and 1-year mortality (36.1% vs 22.1%) were higher with concomitant SAVR but did not reach statistical significance (both P > .05). On Kaplan-Meier analysis, actuarial estimates of cumulative survival were significantly lower with concomitant SAVR at 3 years (56.8% vs 81.1%, P = .020).

CONCLUSIONS

For surgical explantation after TAVR failure, concomitant SAVR is associated with increased mortality. Further studies with longer follow-up are warranted to examine the benefit from earlier intervention before concomitant disease develops.

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.

Challenges and Future Directions in Redo Aortic Valve Reintervention After Transcatheter Aortic Valve Replacement Failure

Transcatheter aortic valve replacement (TAVR) is increasingly being performed in younger and lower surgical risk patients. Reintervention for failed transcatheter heart valves will likely increase in the future as younger patients are expected to outlive the initial bioprosthesis. While redo-TAVR has emerged as an attractive and less invasive alternative to surgical explantation (TAVR-explant) to treat transcatheter heart valve failure, it may not be feasible in all patients due to the risk of coronary obstruction and impaired coronary access. Conversely, TAVR-explant can be offered to most patients who are surgical candidates, but the reported outcomes have shown high mortality and morbidity. This review provides the latest evidence, current challenges, and future directions on redo-TAVR and TAVR-explant for transcatheter heart valve failure, to guide aortic valve reintervention and facilitate patients' lifetime management of aortic stenosis.