Valve-in-valve procedure: importance of the anatomy of surgical bioprostheses

Successful Rescue Transaortic Valve Replacement Using Edwards Sapien 3 Following Failed Evolut R Implantation in a Degenerated Surgical Bioprosthesis: A Case Report

This study examines a complex scenario of structural valve degeneration (SVD) in a high surgical-risk patient with a previously implanted 25 mm Carpentier-Edwards (CE) Perimount Magna Ease 3300 (Irvine, CA: Edwards Lifesciences) surgical bioprosthetic valve (SAV), the patient presented with both paravalvular leak (PVL) and central prosthetic valve insufficiency (PVI). The patient was considered for a transaortic valve-in-valve (ViV) intervention with a self-expanding 29 mm Evolut R valve (Minneapolis, MN: Medtronic). The case describes a ViV intervention complicated by the malpositioning of the Evolut R valve secondary to micro-dislodgement into the left ventricular outflow tract (LVOT) after deployment and subsequent migration into the LVOT during an attempted bioprosthetic valve fracture (BVF) of the SAV that aimed to decrease transvalvular gradients. The resulting acute severe PVL resulted in significant hemodynamic deterioration, necessitating emergent intervention by implanting a balloon-expandable 26 mm Edwards SAPIEN 3 valve (Irvine, CA: Edwards Lifesciences), effectively averting the need for a surgical valve explant. This study illuminates the intricacies and emergency management strategies in transcatheter aortic valve replacement (TAVR) procedures, particularly in high-risk patients with SVD, and offers critical insights into the challenges and solutions in ViV implantations.

Repeated valve replacement: approaches and devices (literature review)

Bioprosthetic valve dysfunction represent a serious drawback that limits the wider clinical use of these medical devices for valvular heart disease surgery. Modern studies describe the view of pathophysiologists on this problem as a multifactorial multi-stage process that causes irreversible changes in bioprosthesis components, ultimately leading to its dysfunction. However, in addition to under- standing the causes and manifestations of prosthetic valve dys- function, an applied question arises about the treatment strategies — determining the most attenuated and accessible low-risk method/ device. The aim of this review was to analyze and systematize current literature data on methods and designs used in repeated surgical and transcatheter interventions on heart valves.

Retrograde aortic access during ventricular tachycardia ablation: Indications, techniques, and challenges

The retrograde aortic (RA) route is a widely used access route for mapping and ablation of ventricular tachycardias (VT) arising from the left ventricular endocardium. With the expanding role of VT ablation in patients with significant comorbidity, the choice between the RA and transseptal access routes is an increasingly important consideration. An individualized decision based on the location of the arrhythmogenic substrate, vascular anatomy, aortic valve morphology, and operator experience is necessary when deciding on the optimal access route. Among patients with challenging vascular anatomy, growing experience from structural interventions such as transcatheter aortic valve replacements and peripheral vascular interventions has provided valuable insights into techniques for safe retrograde access. The present review focuses on patient selection for RA access, potential complications associated with the technique, and optimal approaches for access in patients with challenging vascular or aortic valve anatomy.

Valve-in-valve outcome: design impact of a pre-existing bioprosthesis on the hydrodynamics of an Edwards Sapien XT valve

Objectives

Bioprosthetic aortic heart valves are increasingly implanted in younger patients. Therefore, a strategy for potential valve failure should be developed before implanting the 'first valve'. The goal of this in vitro study was to provide insight into the effects of the design of a bioprosthesis on a valve-in-valve implanted Sapien XT valve.

Methods

The hydrodynamic performance of a 23-mm Sapien XT valve implanted in Vascutek Aspire, Edwards Perimount, Medtronic Mosaic and St. Jude Medical Trifecta heart valves was investigated in a left heart simulator. In addition to the hydrodynamic results, the leaflet dynamics were analysed in high-speed video recordings of the tests.

Results

All valve-in-valve combinations in this study fulfilled the minimum acceptance criteria defined by relevant approval standards (e.g. ISO 5840) but displayed significant differences in their performances. Small inner diameters of the bioprostheses were associated with increased mean pressure gradients, decreased effective orifice areas and geometric opening areas as well as with pin-wheeling and uneven leaflet motion. In addition, implantation in bioprostheses with internally mounted leaflets was associated with lower paravalvular leakage.

Conclusions

The results of this study suggest that a surgical bioprosthesis with a large inner diameter and internally mounted leaflets improves the heamodynamics and potentially the durability of a valve-in-valve combination. These results should give the attending physicians critical information to consider when deciding on a bioprosthesis for younger patients.

Radiopaque Marker Addition During Aortic Root Replacement With the Use of a Freestyle Porcine Bioprosthesis

Aortic root replacement is indicated for aortic root aneurysm, small aortic root, and most root abscesses. This report describes the placement of a radiopaque marker during aortic root replacement using a Freestyle porcine bioprosthesis. This marker is a useful landmark during fluoroscopy for transcatheter valve-in-valve aortic valve replacement in the event of bioprosthesis degeneration.

Challenges in valve-in-valve therapy

At present, the majority of surgical heart valves (SHVs) implanted are bioprosthetic valves. Over time however, these are prone to structural deterioration, which may manifest as valvular stenosis, regurgitation or a combination of the two. Re-operation is the current standard of care for these patients but this itself carries a significant risk of mortality and morbidity. As a natural extension of transcatheter aortic valve implantation (TAVI), now an evidence based solution for severe aortic stenosis in high-risk patients, valve-in-valve (VIV) therapy is evolving into an alternative option in selected patients with structural biological valvular deterioration in all four-valve positions. The first of these VIV procedures was performed in Germany in 2007, for failing aortic valve prosthesis and later, reported in other positions. As with any novel emerging therapy, there is a learning curve to the procedure and the operator must be aware of the potential challenges. In this review we describe some of these challenges with the aim of providing awareness as well as guidance on attaining a successful outcome.