TAVI for failing surgical aortic bioprostheses (valve-in-valve)

Among elderly subjects undergoing surgical aortic valve replacement (SAVR), implantation of bioprosthetic heart valves is considered to be the standard of care. These prostheses are recommended for patients ≥60 years of age or in those at high risk of bleeding with systemic anticoagulation. Consequently, the use of bioprosthetic heart valves now greatly outweighs their mechanical equivalents. Despite advances in prosthetic design, valve durability remains the Achilles’ heel; current iterations are expected to degenerate within 12 to 20 years and in some cases even sooner. Redo SAVR is recommended for stenotic or regurgitant bioprosthesis, through surgery is often denied due to elevated operative risk in these elderly patients with comorbid medical conditions. In such patients, implantation of a transcatheter aortic valve (TAV) within the degenerated bioprosthetic surgical aortic valve (SAV) has proven to be feasible, safe, and effective. Nevertheless, limitations of TAV-in-SAV implantation include a relatively higher rate of malposition and coronary occlusion, device underexpansion, and residual aortic stenosis, compared to TAVI for native aortic valve stenosis. This section aims to describe the pre-procedural planning, implantation techniques, and evidence for TAV-in-SAV procedures.

By Darren Mylotte, Vinayak Bapat, Danny Dvir, Ran Kornowski, Rüdiger Lange and Nicolo Piazza.