Valve-in-Valve Implantation Using the ACURATE Neo in Degenerated Aortic Bioprostheses

Enhancing Transcatheter Aortic Valve Implantation (TAVI) outcomes through virtual proctoring: a case series analysis

Transcatheter Aortic Valve Implantation (TAVI) represents a pivotal advancement in the management of severe aortic stenosis, offering a minimally invasive alternative to surgical valve replacement. Despite its widespread adoption, the complexity of TAVI procedures, especially in high-risk anatomical scenarios such as valve-in-valve interventions, necessitates ongoing educational support for operators. This article explores the implementation of a virtual proctoring system for complex TAVI procedures, evaluating its feasibility, educational value, and impact on procedural success and safety.

Comparison of two self-expanding transcatheter heart valves for degenerated surgical bioprostheses: the AVENGER multicentre registry

BACKGROUND

There is a lack of comparative data on transcatheter aortic valve implantation (TAVI) in degenerated surgical prostheses (valve-in-valve [ViV]).

AIMS

We sought to compare outcomes of using two self-expanding transcatheter heart valve (THV) systems for ViV.

METHODS

In this retrospective multicentre registry, we included consecutive patients undergoing transfemoral ViV using either the ACURATE neo/neo2 (ACURATE group) or the Evolut R/PRO/PRO+ (EVOLUT group). The primary outcome measure was technical success according to Valve Academic Research Consortium (VARC)-3. Secondary outcomes were 30-day all-cause mortality, device success (VARC-3), coronary obstruction (CO) requiring intervention, rates of severe prosthesis-patient mismatch (PPM), and aortic regurgitation (AR) ≥moderate. Comparisons were made after 1:1 propensity score matching.

RESULTS

The study cohort comprised 835 patients from 20 centres (ACURATE n=251; EVOLUT n=584). In the matched cohort (n=468), technical success (ACURATE 92.7% vs EVOLUT 88.9%; p=0.20) and device success (69.7% vs 73.9%; p=0.36) as well as 30-day mortality (2.8% vs 1.6%; p=0.392) were similar between the two groups. The mean gradients and rates of severe PPM, AR ≥moderate, or CO did not differ between the groups. Technical and device success were higher for the ACURATE platform among patients with a true inner diameter (ID) >19 mm, whereas a true ID ≤19 mm was associated with higher device success - but not technical success - among Evolut recipients.

CONCLUSIONS

ViV TAVI using either ACURATE or Evolut THVs showed similar procedural outcomes. However, a true ID >19 mm was associated with higher device success among ACURATE recipients, whereas in patients with a true ID ≤19 mm, device success was higher when using Evolut.

Redo Transcatheter Aortic Valve Implantation in the Lotus Mechanically Expanded Transcatheter Heart Valve: Bench-Top Analysis, Clinical Experience, and Procedural Guidance

BACKGROUND

Redo transcatheter aortic valve implantation (TAVI) is increasing as patients outlive their transcatheter heart valves (THVs) and present with bioprosthetic valve failure. The Lotus mechanically expanded THV has unique design characteristics, which have specific implications for Redo TAVI.

METHODS

The design features of the Lotus valve and their relevance to Redo TAVI were reviewed. Bench-top analysis of Redo TAVI was performed using different contemporary THVs. Procedural and outcome data were obtained from 10 patients who had undergone Redo TAVI for Lotus bioprosthetic valve failure in 5 centers. Recommendations for performing Redo TAVI in Lotus are made, based on these findings.

RESULTS

The Lotus leaflets extend from the frame inflow, with a Neoskirt of only 13 mm, hence a low risk of coronary obstruction during Redo TAVI. The Lotus frame posts prevent full apposition of the Redo prosthesis in the upper part of the frame, while implantation of the Redo THV above the Lotus inflow leads to inadequate apposition of the Lotus leaflets. Inflow-to-inflow positioning is therefore recommended for effective sealing and leaflet pinning. The Lotus locking mechanism prevents overexpansion of the frame, limiting Redo THV oversizing. Redo TAVI was favorable with SAPIEN 3, Evolut, and Navitor THVs on bench-top analysis but not with ACURATE Neo 2 due to the upper crowns and short stent preventing inflow-to-inflow deployment. Case review demonstrated satisfactory outcomes in 10 patients treated with Evolut (n=6), SAPIEN 3 (n=3), and Portico (n=1) valves, with no mortality, major morbidity, or coronary obstruction. Three patients had residual mean gradient ≥20 mm Hg, including 2 of 3 SAPIEN cases. Guidance on procedural planning, valve choice, sizing, and positioning is provided.

CONCLUSIONS

Redo TAVI in Lotus requires an understanding of unique design characteristics, and adherence to key procedural recommendations, but can be safely and effectively performed with most contemporary valve types.

An Update on New Generation Transcatheter Aortic Valves and Delivery Systems

Over the last 15 years, the management of aortic valve disease has been changed by transcatheter aortic valve replacement, which has become the standard of care across the entire spectrum of surgical risk. As a result of continuous evolution of this technique, several next-generation transcatheter heart valves (THVs) have been developed to minimize procedural complications and improve patient outcomes. This review aims to provide an update on the new generation THVs and delivery systems.

First transfemoral TAV-in-TAV implantation of an ACURATE neo2 into a degenerated Lotus prosthesis

We report the first transcatheter aortic valve (TAV)-in-TAV implantation of an ACURATE neo2 into a degenerated Lotus prosthesis. Despite the good final result in this case, TAV-in-TAV of the ACURATE neo2 into a Lotus prosthesis may not be the first choice, as potential pitfalls must be taken into account.

Transcatheter aortic valve implantation for degenerated surgical aortic bioprosthesis: A systematic review

Background:

Transcatheter aortic valve in valve (Aviv) replacement has been shown to be an effective therapeutic option in patients with failed aortic bioprosthetic valves. This review intended to evaluate contemporary 1-year outcomes of Aviv in recent studies.

Methods:

A systematic review on outcomes of Aviv was performed using the best available evidence from studies obtained using a MEDLINE, Cochrane database, and SCOPUS search. Endpoints of interest were survival, coronary artery obstruction, prosthesis-patient mismatch (PPM), stroke, pacemaker implantation, and structural valve deterioration.

Results:

A total of 3339 patients from 23 studies were included. Mean age was 68–80 years, 20%–50% were female, and Society of Thoracic Surgeons score ranged from 5.7 to 31.1. Thirty-day all-cause mortality ranged from 2% to 8%, and 1-year all-cause mortality ranged from 8% to 33%. Coronary artery obstruction risk after Aviv ranged from 0.6% to 4%. One-year stroke ranged from 2% to 8%. Moderate-severe PPM occurred in 11%–58%, and pacemaker rate at 1 year ranged from 5% to 12%.

Conclusion:

Transcatheter aortic ViV has emerged as an effective therapeutic option to treat patients with failed bioprostheses. The acceptable complication rate and favorable 1-year outcomes make Aviv an appropriate alternative to redo surgical aortic valve replacement.

New Challenging Scenarios in Transcatheter Aortic Valve Implantation: Valve-in-valve, Bicuspid and Native Aortic Regurgitation

Transcatheter aortic valve implantation (TAVI) is the most frequently performed structural technique in the field of interventional cardiology. Initially, this procedure was only used in patients with severe symptomatic aortic stenosis and prohibitive risk. Now, barely one decade after its introduction, TAVI indications extend to low- and intermediate-risk patients. Despite these advances, several challenging scenarios are still on the periphery of the evidence base for TAVI. These include valve-in-valve procedures, lower-risk patients with bicuspid aortic valve and the treatment of pure aortic regurgitation. Whereas the valve-in-valve indication has expanded rapidly, evidence for the use of TAVI compared with conventional surgery for bicuspid aortic valve is limited, including the best choice of device should TAVI be used. Evidence for TAVI in pure aortic regurgitation is still anecdotal because of suboptimal outcomes. Operators worldwide have described variations in the TAVI procedural technique to achieve commissural alignment and to minimise the rate of pacemaker use through cusp overlap implantation. In light of the potential clinical benefits, this may also be an area of further development. This review aims to discuss the current evidence available supporting the use of TAVI for these new indications.

Two-in-one: A case report of a touchy TAVI procedure with a new valve

Implantation of a second transcatheter heart valve (THV) into a primary THV is a bail-out situation, but may be necessary. An 85-year-old woman was referred with severe symptomatic aortic stenosis (AS). Echocardiography showed a moderately calcified AS. Computed tomography resulted in an average annular diameter of 22.3 mm and an area of 371 mm² , leading to M-sized ACURATE NEO implantation. Deployment of the upper valve part was uneventful. During lower valve part deployment, the valve dived into the left ventricle outflow tract with the stabilization arches above the annular plane. With the SAFARI guidewire in place, a second M-sized ACURATE NEO was implanted higher inside the first displaced valve. Deployment was straightforward, with no aortic leak, no mitral regurgitation and the patient had normal hemodynamic parameters. Follow-up was uneventful. Positioning a second ACURATE NEO into a failing primary ACURATE NEO is feasible and safe, with favorable short and longer-term outcome.

Computed tomography analysis of coronary ostia location following valve-in-valve transcatheter aortic valve replacement with the ACURATE neo valve: Implications for coronary access

BACKGROUND

Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) is an emerging alternative to re-do surgery. However, the challenge of coronary access (CA) following ViV-TAVR is a potential limitation as TAVR expands to younger lower-risk populations.

OBJECTIVES

Using post-implantation computed tomography (CT) scans to evaluate the geometrical relationship between coronary ostia and valve frame in patients undergoing ViV-TAVR with the ACURATE neo valve.

METHODS

Post-implant CT scans of 18 out of 20 consecutive patients treated with the ACURATE neo valve were analyzed. Coronary ostia location in relation to the highest plane (HP) (highest point of the ACURATE neo or surgical valve) was determined. Ostia located below the highest plan were further subclassified according to the gap available between the transcatheter heart valve frame and ostium (transcatheter-to-coronary [TTC] distance). The impact implantation depth has on these geometrical relationships was evaluated.

RESULTS

A total of 21 out of 36 coronary ostia (58%) were located below the level of the HP with the left coronary artery (36%) more likely to be affected than the right (22%). Further sub-classification of these ostia revealed a large (>6 mm), moderate (4-6 mm), and small (<4 mm) TTC distance in 57% (12/21), 38% (8/21), and in 6% (1/18) of cases, respectively. At an implantation depth <4 mm compared to >4 mm, all ostia were located below the HP with no difference in post-procedural mean gradients (14.5 mmHg ± 4.7 vs. 12.6 mmHg ± 5.8; p = .5, 95%CI 3.8-7.5).

CONCLUSIONS

CA following ACURATE neo implantation for ViV-TAVR could potentially be challenging in a significant proportion of patients and specific consideration should be given to the implantation depth.

Acurate Neo Implantation to Treat Degenerative Regurgitation of Surgical Bioprostheses

Valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) provides a safe and effective treatment option for failing surgical aortic bioprostheses. Self-expanding supra-annular valves offer optimal haemodynamics for this clinical application. The Acurate Neo transcatheter heart valve (THV) offers further unique advantages with stabilisation arches to assist with alignment, upper crowns to restrain bioprosthetic valve leaflets, rapid final opening coaxial to the left ventricular outflow tract and an open design that optimises future coronary access. We report our procedural technique and experience using the Acurate Neo THV in four VIV-TAVR implantations for patients aged between 70 and 81 yrs. All patients presented with severe symptomatic valvular aortic regurgitation (AR), one of whom was in cardiogenic shock. The patients had malfunctioning surgical bioprostheses (stented n = 3; stentless n = 1) ranging in size from 21 to 25 mm. The Acurate Neo THV was successfully implanted in all patients without any complications, residual AR, coronary compromise or need for permanent pacing. Length of stay was 2 to 7 days. Follow-up to 12 months revealed no adverse events. The Acurate Neo THV is an attractive self-expanding option for patients with AR due to degeneration of a surgical aortic valve bioprosthesis.

ACURATE neo: How Is This TAVR Valve Doing to Fit into an Increasingly Crowded Field?

Purpose of Review

Critical appraisal of the available evidence on the self-expanding ACURATE neo transcatheter heart valve (THV) for the treatment of aortic valve disease.

Recent Findings

In an investigator-initiated, multicenter, randomized non-inferiority trial with broad inclusion criteria, ACURATE neo failed to meet non-inferiority compared with SAPIEN 3 with regard to a primary composite safety and efficacy endpoint at 30 days. The difference was driven by higher rates of moderate or severe paravalvular regurgitation and higher rates of acute kidney injury. In turn, registry data suggest that the safety and efficacy profile of the ACURATE neo is comparable to that of other commercially available devices. Randomized evidence indicated favorable hemodynamic results with large effective orifice areas and low residual gradients.

Summary

The self-expanding ACURATE neo THV is associated with higher rates of residual aortic regurgitation compared to the balloon-expandable SAPIEN 3 THV. The supra-annular design with low residual gradients may be advantageous in patients with small anatomy and mild degree of calcification.