Redo-transcatheter aortic valve replacement with the supra-annular, self-expandable Evolut platform: Insights from the Transcatheter valve Therapy Registry

REdo transcatheter aortic VALVE implantation for the management of transcatheter aortic valve failure: Design and rationale of the REVALVE study

BACKGROUND

The expansion of transcatheter aortic valve implantation (TAVI) into younger and lower risk patients increases the likelihood of future reintervention on the valve due to bioprosthetic valve failure (BVF). However, little is known about the feasibility and outcomes of redo TAVI for BVF.

METHODS

REVALVE is an investigator-initiated, open-label, prospective registry, enrolling 300 patients undergoing redo TAVI in approximately 75 centres in 11 countries in Europe and the Middle East. The primary endpoint is REVALVE success at 30-days, adapted from the Valve Academic Research Consortium-3 (VARC-3) criteria and defined as the correct positioning of a single prosthetic heart valve into the proper anatomic location, intended performance of the valve (mean gradient <20 mmHg, peak velocity < 3.0 m/s, doppler velocity index ≥0.25,

CONCLUSIONS

The REVALVE study is a prospective multi-centre study investigating the management of TAV failure by redo TAVI, with parallel cohorts treated by surgical AVR and optimal medical therapy.

CLINICAL TRIAL REGISTRATION

www.

CLINICALTRIALS

gov; NCT06557798.

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Key Words

• BVF
• REVALVE
• Redo TAVI

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Affiliation(s)

Daniel J Blackman Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK.
Suleman Aktaa Department of Cardiology, St. Paul's Hospital, Vancouver, BC, Canada; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
David Pickles Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Mohamed Abdel-Wahab Heart Center, University of Leipzig, Leipzig, Germany; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Ole De Backer Rigshospitalet, Copenhagen University Hospital, Copenhagen, Denmark; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Nicolas M Van Mieghem Erasmus University Medical Center, Rotterdam, the Netherlands; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Hendrik Treede University Medical Center of the Johannes Gutenberg University, Mainz, Germany; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Uri Landes Department of Cardiology, Bnai-Zion Medical Center, Haifa, Israel; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Vinayak Bapat Valve Science Center, Minneapolis Heart Institute Foundation, Abbott Northwestern Hospital, Minneapolis, MN, USA; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
David Hildick-Smith Department of Cardiology, Royal Sussex County Hospital, Brighton, United Kingdom; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK
Marco Barbanti Università degli Studi di Enna Kore, Enna, Italy; Department of Cardiology, Leeds Teaching Hospitals NHS Trust, Leeds, UK

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What Are SAVR Indications in the TAVI Era?

While surgical aortic valve replacement (SAVR) has traditionally been regarded as the gold standard for severe symptomatic aortic stenosis (AS), transcatheter aortic valve implantation (TAVI) has emerged as a compelling less invasive alternative for patients with severe AS across the entire surgical risk spectrum. Despite TAVI's increasing utilization and promising outcomes, SAVR continues to be an essential treatment modality for certain patient populations, including individuals with complex aortic anatomies unsuitable for TAVI, patients presenting with significant aortic regurgitation, individuals requiring concomitant surgical procedures, and cases involving infective endocarditis. Furthermore, concerns regarding the long-term durability and complication profile of transcatheter valves underscore the importance of individualized patient assessment, especially for younger patients requiring optimal lifetime management strategies. This review examines the evolving role of SAVR amidst the growing adoption of TAVI and highlights key considerations for selecting the most appropriate treatment strategy for patients with aortic valve disease, incorporating insights from recent advancements in transcatheter technologies and the latest clinical trial evidence.

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 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.

Outcomes of repeat transcatheter aortic valve replacement with balloon-expandable valves: a registry study

BACKGROUND

With increasing numbers of patients undergoing transcatheter aortic valve replacement (TAVR), data on management of failed TAVR, including repeat TAVR procedure, are needed. The aim of this study was to assess the safety and efficacy of redo-TAVR in a national registry.

METHODS

This study included all consecutive patients in the Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy Registry from Nov 9, 2011, to Dec 30, 2022 who underwent TAVR with balloon-expandable valves in failed transcatheter heart valves (redo-TAVR) or native aortic valves (native-TAVR). Procedural, echocardiographic, and clinical outcomes were compared between redo-TAVR and native-TAVR cohorts using propensity score matching.

FINDINGS

Among 350 591 patients (1320 redo-TAVR; 349 271 native-TAVR), 1320 propensity-matched pairs of patients undergoing redo-TAVR and native-TAVR were analysed (redo-TAVR cohort: mean age 78 years [SD 9]; 559 [42·3%] of 1320 female, 761 [57·7%] male; mean predicted surgical risk of 30-day mortality 8·1%). The rates of procedural complications of redo-TAVR were low (coronary compression or obstruction: four [0·3%] of 1320; intraprocedural death: eight [0·6%] of 1320; conversion to open heart surgery: six [0·5%] of 1319) and similar to native-TAVR. There was no significant difference between redo-TAVR and native-TAVR populations in death at 30 days (4·7% vs 4·0%, p=0·36) or 1 year (17·5% vs 19·0%, p=0·57), and stroke at 30 days (2·0% vs 1·9%, p=0·84) or 1 year (3·2% vs 3·5%, p=0·80). Redo-TAVR reduced aortic valve gradients at 1 year, although they were higher in the redo-TAVR group compared with the native-TAVR group (15 mm Hg vs 12 mm Hg; p<0·0001). Moderate or severe aortic regurgitation rates were similar between redo-TAVR and native-TAVR groups at 1 year (1·8% vs 3·3%, p=0·18). Death or stroke after redo-TAVR were not significantly affected by the timing of redo-TAVR (before or after 1 year of index TAVR), or by index transcatheter valve type (balloon-expandable or non-balloon-expandable).

INTERPRETATION

Redo-TAVR with balloon-expandable valves effectively treated dysfunction of the index TAVR procedure with low procedural complication rates, and death and stroke rates similar to those in patients with a similar clinical profile and predicted risk undergoing TAVR for native aortic valve stenosis. Redo-TAVR with balloon-expandable valves might be a reasonable treatment for failed TAVR in selected patients.

FUNDING

Edwards Lifesciences.

The Use of BASILICA Technique to Prevent Coronary Obstruction in a TAVI-TAVI Procedure

Transcatheter aortic valve implantation (TAVI) to manage structural bioprosthetic valve deterioration has been successful in mitigating the risk of a redo cardiac surgery. However, TAVI-in-TAVI is a complex intervention, potentially associated with feared complications such as coronary artery obstruction. Coronary obstruction risk is especially high when the previously implanted prosthesis had supra-annular leaflets and/or the distance between the prosthesis and the coronary ostia is short. The BASILICA technique (bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction) was developed to prevent coronary obstruction during native or valve-in-valve interventions but has now also been considered for TAVI-in-TAVI interventions. Despite its utility, the technique requires a not so widely available toolbox. Herein, we discuss the TAVI-in-TAVI BASILICA technique and how to perform it using more widely available tools, which could spread its use.