Valve-in-valve transcatheter aortic valve implantation for failing surgical aortic stentless bioprosthetic valves: A single-center experience

Background: Valve-in-valve (ViV) transcatheter aortic implantation (TAVI) is an alternative to redo surgery for patients with a failing aortic bioprosthesis. A lack of anatomic markers may complicate the procedure. This study reports procedural and midterm outcomes of patients undergoing ViV-TAVI for failing stentless bio-prostheses, at a single institution. Methods: A total of 22 consecutive patients with failing homograft (n = 17), stented porcine valve (n = 3), aortic root bioprosthesis (n = 1), or native resuspended aortic valve (n = 1) (aged 74 +/- 12 years; Society of Thoracic Surgeons 30-day predicted risk of mortality score: 14% +/- 8%) were treated with ViV-TAVI, between 2007 and 2014. All had severe aortic regurgitation and were highly symptomatic before TAVI: 41% had chronic kidney disease; 32% had undergone previous coronary bypass grafts; 27% had previous percutaneous coronary intervention; 14% had severe pulmonary disease; 14% had had a stroke. All underwent TAVI with a self-expanding device. Results: The 30-day mortality was 0%. No cases occurred of myocardial infarction, tamponade, stroke, severe bleeding, acute kidney injury, or major vascular complications. Three instances of device migration, and 1 of device embolization, occurred. Permanent pacing was required in 14%. Paravalvular aortic regurgitation was absent or mild in 19, and mild to moderate in 3. Average hospital stay was 8 +/- 3 days; all patients were discharged home. Six-month and 1-year mortality was 4.8% and 14.3%, respectively. Aortic valve area and paravalvular aortic regurgitation were unchanged at 1 year. Conclusions: The ViV-TAVI procedure may be performed in high-risk patients with a degenerate stentless bioprosthesis with low 30-day mortality, and 1-year mortality of 14.3%. Although technically challenging, owing to a lack of anatomic markers, satisfactory positioning is possible in most cases, with excellent clinical and echocardiographic outcomes.