Bioprosthetic valve fracture for valve-in-valve transcatheter aortic valve implantation in patients with structural valve degeneration: Systematic review with meta-analysis

Bioprosthetic Valve Fracture for Transcatheter Aortic Valve-in-Valve Replacement: A Systematic Literature Review

Transcatheter aortic valve-in-valve replacement presents a viable, minimally invasive approach to replacing degraded bioprosthetic surgical valves. The major drawback of this technique is poor hemodynamics in the form of patient-prosthesis mismatch and high transvalvular gradients. This is commonly attributable to the reduced valvular diameter from the transcatheter heart valve fixed inside the degraded bioprosthesis. Maximizing this diameter by bioprosthetic valve fracture occurs through a noncompliant, high-pressure balloon to splay the degraded valve outward. Despite its novelty, this has demonstrated improved hemodynamic outcomes and optimal valvular expansion with slightly increased operative risk. In this review, we highlight the technique of bioprosthetic valve fracture, types of suitable balloons and valves, timing in relation to valve-in-valve implantation, safety and efficacy, implications, and future directions.

Aortic Valve-in-Valve Procedures: Challenges and Future Directions

Aortic valve-in-valve (ViV) procedures are increasingly performed for the treatment of surgical bioprosthetic valve failure in patients at intermediate to high surgical risk. Although ViV procedures offer indisputable benefits in terms of procedural time, in-hospital length of stay, and avoidance of surgical complications, they also present unique challenges. Growing awareness of the technical difficulties and potential threats associated with ViV procedures mandates careful preprocedural planning. This review article offers an overview of the current state-of-the-art ViV procedures, with focus on patient and device selection, procedural planning, potential complications, and long-term outcomes. Finally, it discusses current research efforts and future directions aimed at improving ViV procedural success and patient outcomes.

Late Survival After Valve-in-Valve Transcatheter Aortic Valve Implantation With Balloon- Versus Self-Expandable Valves: Meta-Analysis of Reconstructed Time-to-Event Data

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) in patients with failed bioprostheses arose as an alternative to redo surgical aortic valve replacement. There is an increasing interest in exploring the differences between self-expanding valves (SEVs) and balloon-expandable valves (BEVs). Our study aimed to evaluate the all-cause mortality in ViV-TAVI with SEV versus BEV in patients with failed bioprostheses. We performed a study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of studies published by March 30, 2023. A total of 5 studies met our eligibility criteria and included 1,454 patients who underwent ViV-TAVI (862 with SEV and 592 with BEV). Almost all BEVs were iterations of the Edwards BEVs (SAPIEN, SAPIEN XT, and SAPIEN 3) and almost all SEVs were iterations of the Medtronic SEVs (CoreValve/Evolut). During the first year after ViV-TAVI, 67 deaths (11.8%) occurred in patients treated with BEV compared with 92 deaths (11.1%) in patients treated with SEV (hazard ratio 0.92, 95% confidence interval 0.66 to 1.27, p = 0.632). At 8 years of follow-up, the all-cause death was not statistically significantly different between the groups, with mortality rates of 65.4% in the group treated BEV and 58.8% in the group treated with SEV (hazard ratio 0.91, 95% confidence interval 0.75 to 1.09, p = 0.302). The restricted mean survival time was overall 0.25 years greater with SEV than BEV, but this difference was not statistically significant (p = 0.278), which indicates no lifetime gain or loss with SEV in comparison with BEV. There seems to be no difference in terms of all-cause death in ViV-TAVI with SEV versus BEV. Randomized controlled trials are warranted to validate our results.

Comparison of in-hospital outcomes and long-term survival for valve-in-valve transcatheter aortic valve replacement versus the benchmark native valve transcatheter aortic valve replacement procedure

Background

In recent years, the number of patients with failed surgically implanted aortic bioprostheses and the number of candidates for valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) have been increasing.

Objectives

The purpose of this study is to evaluate the efficacy, safety, and long-term survival outcomes of VIV-TAVR compared with the benchmark native valve transcatheter aortic valve replacement (NV-TAVR).

Methods

A cohort study was conducted on patients who underwent TAVR in the department of cardiology at Toulouse University Hospital, Rangueil, France between January 2016 and January 2020. The study population was divided into two groups: NV-TAVR (N = 1589) and VIV-TAVR (N = 69). Baseline characteristics, procedural data, in-hospital outcomes, and long-term survival outcomes were observed.

Results

In comparison with NV-TAVR, there are no differences in TAVR success rate (98.6 vs. 98.8%, p = 1), per-TAVR complications (p = 0.473), and length of hospital stay (7.5 ± 50.7 vs. 4.4 ± 2.8, p = 0.612). The prevalence of in-hospital adverse outcomes did not differ among study groups, including acute heart failure (1.4 vs. 1.1%), acute kidney injury (2.6, 1.4%), stroke (0 vs. 1.8%, p = 0.630), vascular complications (p = 0.307), bleeding events (0.617), and death (1.4 vs. 2.6%). VIV-TAVR was associated with a higher residual aortic gradient [OR = 1.139, 95%CI (1.097-1.182), p = 0.001] and a lower requirement for permanent pacemaker implantation [OR = 0.235 95%CI (0.056-0.990), p = 0.048]. Over a mean follow-up period of 3.44 ± 1.67 years, no significant difference in survival outcomes has been observed (p = 0.074).

Conclusion

VIV-TAVR shares the safety and efficacy profile of NV-TAVR. It also represents a better early outcome but a higher non-significant long-term mortality rate.

Late outcomes of valve-in-valve transcatheter aortic valve implantation versus re-replacement: Meta-analysis of reconstructed time-to-event data

AIMS

To evaluate all-cause mortality in ViV-TAVI versus redo SAVR in patients with failed bioprostheses.

METHODS

Study-level meta-analysis of reconstructed time-to-event data from Kaplan-Meier curves of non-randomized studies published by September 30, 2021.

RESULTS

Ten studies met our eligibility criteria and included a total of 3345 patients (1676 patients underwent ViV-TAVI and 1669 patients underwent redo SAVR). Pooling all the studies, ViV-TAVI showed a lower risk of all-cause mortality in the first 44 days [hazard ratio (HR) 0.67, 95% confidence interval (CI) 0.49-0.93, P = 0.017], with an HR reversal after 197 days favoring redo SAVR (HR 1.53; 95% CI 1.22-1.93; P < 0.001). Pooling only the matched populations (1143 pairs), ViV-TAVI showed a lower risk of all-cause mortality in the first 55 days [hazard ratio (HR) 0.63, 95% confidence interval (CI) 0.45-0.89, P < 0.001], with a reversal HR after 212 days favoring redo SAVR (HR 1.57; 95% CI 1.22-2.03; P < 0.001). The Cox regression model showed a statistically significant association of prosthesis-patient mismatch (PPM) with all-cause mortality during follow-up for ViV-TAVI (HR 1.03 per percentage increase in the study- and treatment arm-level proportion of PPM, 95% 1.02-1.05, P < 0.001).

CONCLUSION

ViV-TAVI is associated with a strong protective effect immediately after the procedure in comparison with redo SAVR, however, this initial advantage reverses over time and redo SAVR seems to be a protective factor for all-cause mortality after 6 months. Considering that these results are the fruit of pooling data from observational studies, they should be interpreted with caution and trials are warranted.

Bioprosthetic Valve Fracture After TAVR Complicated by Balloon Rupture: Bail-Out TAVR in TAVR in SAVR

Transcatheter aortic valve replacement in surgical aortic valve is a safe and effective procedure to treat patients with failed bioprosthetic surgical valves at high risk for reoperation. Performing bioprosthetic valve fracture has been shown to improve postprocedural hemodynamics of TAVR in surgical aortic valve replacement. However, specific complications related to valve fracture are becoming more common. (Level of Difficulty: Advanced.).

Lifetime management of aortic valve disease: Aligning surgical and transcatheter armamentarium to set the tone for the present and the future

Transcatheter aortic valve replacement (TAVR) has already received the green light for high-, intermediate- and low-risk profiles and is an alternative for all patients regardless of age. It is clear that there has been a push towards the use of TAVR in younger and younger patients (<65 years), which has never been formally tested in randomized controlled trials but seems inevitable as TAVR technology makes steady progress. Lifetime management as a concept will set the tone in the field of the structural heart. Some subjects in this scenario arise, including the importance of optimized prosthetic hemodynamics for lifetime care; surgical procedures in the aortic root; management of structural valve degeneration with valve-in-valve procedures (TAVR-in-surgical aortic valve replacement [SAVR] and TAVR-in-TAVR) and redo SAVR; commissural alignment and cusp overlap for TAVR; the rise in the number of surgical procedures for TAVR explantation; and the renewed interest in the Ross procedure. This article reviews all these issues which will become commonplace during heart team meetings and preoperative conversations with patients in the coming years.