Outcomes of Valve-in-Valve Transcatheter Aortic Valve Replacement

Structural valve degeneration is increasingly seen given the higher rates of bioprosthetic heart valve use for surgical and transcatheter aortic valve replacement (TAVR). Valve-in-valve TAVR (VIV-TAVR) is an attractive alternate for patients who are otherwise at high risk for reoperative surgery. We compared patients who underwent VIV-TAVR and native valve TAVR through a retrospective analysis of our institutional transcatheter valve therapy (TVT) database from 2013 to 2022. Patients who underwent either a native valve TAVR or VIV-TAVR were included. VIV-TAVR was defined as TAVR in patients who underwent a previous surgical aortic valve replacement. Kaplan-Meier survival analysis was used to obtain survival estimates. A Cox proportional hazards regression model was used for the multivariable analysis of mortality. A total of 3,532 patients underwent TAVR, of whom 198 (5.6%) underwent VIV-TAVR. Patients in the VIV-TAVR cohort were younger than patients who underwent native valve TAVR (79.5 vs 84 years, p <0.001), with comparable number of women and a higher Society of Thoracic Surgeons risk score (6.28 vs 4.46, p <0.001). The VIV-TAVR cohort had a higher incidence of major vascular complications (2.5% vs 0.8%, p = 0.008) but lower incidence of permanent pacemaker placement (2.5% vs 8.1%, p = 0.004). The incidence of stroke was comparable between the groups (VIV-TAVR 2.5% vs native TAVR 2.4%, p = 0.911). The 30-day readmission rates (VIV-TAVR 7.1% vs native TAVR 9%, p = 0.348), as well as in-hospital (VIV-TAVR 2% vs native TAVR 1.4%, p = 0.46), and overall (VIV-TAVR 26.3% vs native TAVR 30.8%, p = 0.18) mortality at a follow-up of 1.8 years (0.83 to 3.5) were comparable between the groups. The survival estimates were also comparable between the groups (log-rank p = 0.27). On multivariable Cox regression analysis, VIV-TAVR was associated with decreased hazards of death (hazard ratio 0.68 [0.5 to 0.9], p = 0.02). In conclusion, VIV-TAVR is a feasible and safe strategy for high-risk patients with bioprosthetic valve failure. There may be potentially higher short-term morbidity with VIV-TAVR, with no overt impact on survival.

Anatomic considerations after commando double valve reconstruction: insights for future valve-in-valve therapies

OBJECTIVES

The Commando technique for reconstruction of the aortomitral intervalvular fibrous body is effective to facilitate double valve surgery in cases of endocarditis or infiltrative calcification. The length of patch utilized in reconstruction of the intervalvular fibrous body has an important relationship to the geometry of the mitral valve (MV) and aortic valve (AV) and may impact on potential future valve-in-valve (VIV) therapy. Here we report anatomic measurements after Commando reconstruction in a small group of patients and analyse the impact of reconstruction techniques on transcatheter VIV therapies.

METHODS

Seven patients from January 2018 to April 2022 who underwent double valve surgery with the Commando technique with postoperative computed tomography (CT) scans were identified. Computed tomographic reconstruction of the AV and MV was performed using 3mensio software and virtual transcatheter valve replacement was performed. Two of these patients who had preoperative imaging was analysed to assess the change in aortomitral geometry resulting from reconstruction.

RESULTS

Measurements for each patient post-reconstruction are given in the table. Aortomitral length was grossly inversely proportional to aortomitral angle (AMA). AMA and aortomitral curtain (AMC) length were significantly altered post-Commando in 2 analysed patients with pre- and postoperative computed tomography scan. Transcatheter AV and MV replacements were feasible in all patients post-Commando. The AMA was larger and more favorable for mitral VIV in patients in which the AMC was short.

CONCLUSIONS

AMC length, as determined by location of AV annular sutures, may be an important consideration in surgical decision-making for VIV after the Commando procedure.

Effect of Implantation of a new Domestic Prosthesis in the Aortic Position on the Quality of Life of Patients With Degenerative Aortic Stenose, Survival Assessment and Development of Complications 1 Year Post-Surgery

Aim      To evaluate quality of life (QoL), general survival, and development of complications in patents one year after surgical aortic valve (AV) replacement with a MedInzh-BIO xenopericardial carcass prosthesis.Material and methods  Degenerative AV disease is one of the most common cardiovascular diseases that gives place only to ischemic heart disease. Surgical correction of the AV defect should be aimed not only at hemodynamic outcomes but also at improvement of QoL. This study included 91 patients (48 women and 43 men), who were implanted with a MedInzh-BIO biological xenopericardial prosthesis in aortic position from January 2017 through March 2020. Mean age of patients was 69.96±4.4 years. QoL was evaluated with a standard SF-36 questionnaire. Also, survival and complications were analyzed one year after surgery.Results Data analysis before and one year after surgery showed a significant improvement of QoL. Postoperative one-year survival was 95.4 %, and major valve-associated complications were absent in 94.5% of cases. During one year, four patients died after 1, 6, 8, and 10 months of follow-up, respectively.Conclusion      The improvement of QoL following the AV replacement with a novel xenopericardial carcass prosthesis with the "easy change" system indicates the clinical and functional effectiveness of the used method. The results of the study demonstrated improvements of both the physical health component and the subjective emotional assessment. Postoperative one-year survival was 95.4 %, and major valve-associated complications were absent in 94.5% of cases.

Transcatheter valvular therapies in patients with left ventricular assist devices

Aortic, mitral and tricuspid valve regurgitation are commonly encountered in patients with continuous-flow left ventricular assist devices (CF-LVADs). These valvular heart conditions either develop prior to CF-LVAD implantation or are induced by the pump itself. They can all have significant detrimental effects on patients' survival and quality of life. With the improved durability of CF-LVADs and the overall rise in their volume of implants, an increasing number of patients will likely require a valvular heart intervention at some point during CF-LVAD therapy. However, these patients are often considered poor reoperative candidates. In this context, percutaneous approaches have emerged as an attractive “off-label” option for this patient population. Recent data show promising results, with high device success rates and rapid symptomatic improvements. However, the occurrence of distinct complications such as device migration, valve thrombosis or hemolysis remain of concern. In this review, we will present the pathophysiology of valvular heart disease in the setting of CF-LVAD support to help us understand the underlying rationale of these potential complications. We will then outline the current recommendations for the management of valvular heart disease in patients with CF-LVAD and discuss their limitations. Lastly, we will summarize the evidence related to transcatheter heart valve interventions in this patient population.

BAlloon expandable vs. SElf expanding transcatheter vaLve for degenerated bioprosthesIs: design and rationale of the BASELINE trial

BACKGROUND

Surgical aortic valve bioprostheses may degenerate over time and require redo intervention. Transcatheter aortic valve replacement (TAVR) is a less invasive alternative to redo surgery. The BAlloon Expandable vs. SElf Expanding Transcatheter VaLve for Degenerated BioprosthesIs (BASELINE) trial was designed to compare the performance of the balloon-expandable SAPIEN-3 Ultra and the self-expanding EVOLUT PRO+ valve systems in symptomatic patients with a failing surgical bioprosthesis.

METHODS

The BASELINE trial is an investigator-initiated, non-funded, prospective, randomized, open-label, superiority trial enrolling a total of 440 patients in up to 50 sites in 12 countries in Europe and North-America. The primary endpoint is device success at 30-days defined by the Valve Academic Research Consortium-3 Criteria as the composite of technical success, freedom from mortality, freedom for surgery or intervention related to the device or to a major vascular or access-related or cardiac structural complication with an intended performance of the valve (mean gradient <20 mmHg and less than moderate aortic regurgitation). The co-primary endpoint at 1 year is defined as the composite of all-cause death, disabling stroke, rehospitalization for heart failure or valve related problems. Independent Core Laboratories will conduct uniform analyses of echocardiography (pre-, post-, 1-year post-procedure), multi-sliced computed tomography (pre-, and if available post-procedure) and cine-fluoroscopy studies.

CONCLUSIONS

The BASELINE trial is a head-to-head comparative trial investigating the 2 most used contemporary transcatheter heart valves for the treatment of a failing surgical aortic bioprosthesis. (ClinicalTrials.gov number NCT04843072).

Prosthesis Tailoring for Patients Undergoing Transcatheter Aortic Valve Implantation

Transcatheter aortic valve implantation (TAVI) has risen over the past 20 years as a safe and effective alternative to surgical aortic valve replacement for treatment of severe aortic stenosis, and is now a well-established and recommended treatment option in suitable patients irrespective of predicted risk of mortality after surgery. Studies of numerous devices, either newly developed or reiterations of previous prostheses, have been accruing. We hereby review TAVI devices, with a focus on commercially available options, and aim to present a guide for prosthesis tailoring according to patient-related anatomical and clinical factors that may favor particular designs.

Transcatheter Aortic Valve Implantation for Bioprosthetic Valve Failure: Placement of Aortic Transcatheter Valves 3 Aortic Valve-in-Valve Study

Background

Transcatheter aortic valve implantation is safe and effective for high-risk patients with bioprosthetic valve failure (BVF) but has not been studied in low- and intermediate-risk patients. One year outcomes of the PARTNER 3 Aortic Valve-in-valve (AViV) Study were evaluated.

Methods

This prospective, single-arm, multicenter study enrolled 100 patients from 29 sites with surgical BVF. The primary endpoint was a composite of all-cause mortality and stroke at 1 year. The key secondary outcomes included mean gradient, functional capacity, and rehospitalization (valve-related, procedure-related, or heart failure related).

Results

A total of 97 patients underwent AViV with a balloon-expandable valve from 2017 to 2019. Patients were 79.4% male with a mean age of 67.1 years and Society of Thoracic Surgeons score of 2.9%. The primary endpoint occurred in 2 patients (2.1%) who had strokes; there was no mortality at 1 year. Five patients (5.2%) had valve thrombosis events, and 9 patients (9.3%) had rehospitalizations, including 2 (2.1%) for strokes, 1 (1.0%) for heart failure, and 6 (6.2%) for aortic valve reinterventions (3 explants, 3 balloon dilations, and 1 percutaneous paravalvular regurgitation closure). From baseline to 1 year, New York Heart Association class III/IV decreased from 43.3% to 4.5%, mean gradient from 39.1 ± 18.2 mm Hg to 19.7 ± 7.6 mm Hg, and ≥moderate aortic regurgitation from 41.1% to 1.1%.

Conclusions

AViV with a balloon-expandable valve improved hemodynamic and functional status at 1 year and can provide an additional therapeutic option in selected low- or intermediate-risk patients with surgical BVF, although longer term follow-up is necessary.

Trend and early outcomes in isolated surgical aortic valve replacement in the United Kingdom

Objective

Surgical aortic valve replacement (SAVR) is traditionally the gold-standard treatment in patients with aortic valve disease. The advancement of transcatheter aortic valve replacement (TAVR) provides an alternative treatment to patients with high surgical risks and those who had previous cardiac surgery. We aim to evaluate the trend, early clinical outcomes, and the choice of prosthesis use in isolated SAVR in the United Kingdom.

Methods

All patients (n = 79,173) who underwent elective or urgent isolated surgical aortic valve replacement (SAVR) from 1996 to 2018 were extracted from the National Adult Cardiac Surgery Audit database. Patients who underwent additional procedures and emergency or salvage SAVR were excluded from the study. Trend and clinical outcomes were investigated in the whole cohort. Patients who had previous cardiac surgery, high-risk groups (EuroSCORE II >4%), and predicted/observed mortality were evaluated. Furthermore, the use of biological prostheses in five different age groups, that are <50, 50-59, 60-69, 70-79, and >80, was investigated. Clinical outcomes between the use of mechanical and biological aortic valve prostheses in patients <65 years old were analyzed.

Results

The number of isolated SAVR increased across the study period with an average of 4,661 cases performed annually after 2010. The in-hospital/30-day mortality rate decreased from 5.28% (1996) to 1.06% (2018), despite an increasing trend in EuroSCORE II. The number of isolated SAVR performed in octogenarians increased from 596 to 2007 (the first year when TAVR was introduced in the UK) to 872 in 2015 and then progressively decreased to 681 in 2018. Biological prosthesis usage increased across all age groups, particularly in the 60-69 group, from 24.59% (1996) to 81.87% (2018). There were no differences in short-term outcomes in patients <65 years old who received biological or mechanical prostheses.

Conclusion

Surgical aortic valve replacement remains an effective treatment for patients with isolated aortic valve disease with a low in-hospital/30-day mortality rate. The number of patients with high-risk and octogenarians who underwent isolated SAVR and those requiring redo surgery has reduced since 2016, likely due to the advancement in TAVR. The use of biological aortic prostheses has increased significantly in recent years in all age groups.

The role of echocardiography in the management of structural valve degeneration of transcatheter valves

Transcatheter valve implantation in patients with aortic stenosis has evolved as an acceptable alternative to surgical aortic valve replacement in a subset of patients at excessively high risk from surgery. The structural valve degeneration (SVD) is a known phenomenon in catheter-based valves too, which was hitherto seen with surgical bioprosthetic valves. Echocardiography plays a pivotal role not only in early detection but also in the management of SVD of Transcatheter valves. The goal of this report is to agglomerate our experience of an unusual case of SVD of a catheter-based valve implanted inside the bioprosthetic aortic and mitral valve apparatus and its management with aortic and mitral valve replacement with mechanical valve prosthesis.

Predictors of Procedural Success in Patients With Degenerated Surgical Valves Undergoing Transcatheter Aortic Valve-in-Valve Implantation

Background: Valve-in-Valve transcatheter aortic valve implantation (ViV-TAVI) is a growing alternative for redo-surgery in patients with degenerated surgical valves. To our knowledge, data are lacking on the determinants on ViV-TAVI procedural success in patients with degenerated surgical valves.

Methods: All consecutive patients undergoing ViV-TAVI for degenerated surgical valves at the Cleveland Clinic were analyzed. Data were extracted from our patient registry on baseline patient characteristics, echocardiographic parameters, and procedural details. To identify possible predictors of ViV-TAVI procedural success, we employed a multivariate logistic regression model.

Results: A total of 186 patients who underwent ViV-TAVI were analyzed, with procedural success (VARC-2 device success and absence of periprocedural MACCE) reported in 165 (88.7%) patients. Patients with successful ViV-TAVI were significantly younger and had more frequent utilization of the transfemoral access than those with failed procedure. Other baseline and procedural characteristics were comparable between both groups. In terms of echocardiographic parameters, the procedural success group had a significantly lower AV peak pressure gradient (62.1 ± 24.7 vs. 74.1 ± 34.6 mmHg; p = 0.04) and lower incidence of moderate-to-severe aortic regurgitation [AR] (30.4 vs. 55%; p = 0.04). However, no significant differences between both groups were noted in terms of AV mean pressure gradient and left ventricular measurements. In multivariate analysis, lower AV peak pressure gradient (OR = 0.97, 95% CI: 0.95–0.99) and absence of moderate-to-severe AR (OR = 0.65, 95% CI: 0.44–0.95) at baseline emerged as independent predictors of ViV-TAVI procedural success.

Conclusion: Valve-in-Valve TAVI for degenerated surgical valves is a feasible approach with high success rates, especially in those with lower AV peak pressure gradient and absence of moderate-to-severe AR. Studies with larger sample size and longer follow-up are required to further characterize the predictors of ViV-TAVI success and other clinical outcomes.

The selection of transcatheter heart valves in transcatheter aortic valve replacement

Transcatheter heart valve technology has rapidly progressed since initial approval in the United States. There are currently two widely available transcatheter heart valve delivery systems approved in the US; however limited data exist on optimal device selection for various patient populations. This review explores the characteristics of currently approved transcatheter heart valve systems and scenarios where one valve system may be favored over others. We provide a simplified decision tree for selecting the optimal transcatheter valve system for specific patient-centered characteristics.

Transcatheter Aortic Valve Replacement with a Self-Expanding Prosthesis

The self-expanding transcatheter heart valve (Medtronic Cardiovascular Corevalve and Evolut) is a supra-annular, trileafet porcine pericardial valves on a diamond lattice nickel-titanium alloy frame. The TAVR device has undergone significant improvements in design and procedural techniques to further increase safety, efficacy, and durability since they it was first released. Unique design characteristics, as well as patient and procedural factors, favor self-expanding over balloon-expandable prostheses in certain situations. The self-expanding transcatheter heart valve has proven to be an excellent option for severe aortic stenosis patients with any level of surgical risk and preliminary data suggest a comparable durability to surgical tissue valves.

Valve-in-Valve Transcatheter Aortic Valve Replacement, with Present-Day Innovations and Up-to-Date Techniques

Approximately 51,000 to 65,000 surgical aortic valve replacement (SAVR) cases are performed in the United States anually. Bioprosthetic degeneration commonly occurs within 10 to 15 years, and nearly 800 redo SAVR cases occur each year. Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has emerged as a safe and effective alternative, as the Food and Drug Administration approved ViV TAVR with self-expanding transcatheter heart valve in 2015 and balloon-expandable valve in 2017 for failed surgical valves cases at high risk of reoperation. We review ViV TAVR, with specific attention to procedural planning, technical challenges, associated complications, and long-term follow-up.

Freestyle Aortic Bioprostheses in Patients 60 Years old and Younger

Evaluate outcomes of the Freestyle stentless aortic bioprosthesis in patients 60 years old and younger. All patients, 60 years old and younger, between January 1, 1998 to December 31, 2015 who underwent implantation of a Freestyle aortic valve at a single institution were reviewed. Medical records and telephone interviews were utilized for data collection. 515 patients were identified with an average age of 51.3 years. Mean follow up was 11.1 years. 225 full root replacements and 290 subcoronary implants were performed. Overall survival, including patients with concomitant procedures, at 15 years was 63.7% (95% CI 58.3-68.5). Isolated subcoronary implants (58%,167/290) had a 15-year survival of 71.6% (95% CI 62.6-78.7) vs 78.4% (95% CI 69.7, 84.9) for isolated root replacements (63%,141/225) which was not statistically significant (P = 0.397). No significant difference in operative SVD at 15 years occurred between full root replacements 37.6% (95% CI 27.2-50.2) vs subcoronary implants 39.4% (95% CI31.1, 49.0). 110 patients required reoperation solely for intrinsic SVD. 93% (102/110) failed due to aortic insufficiency. Of reoperative interventions for SVD, 37% (41/110) of patients required urgent reoperation and 4.5% (5/110) required emergent reoperation. Pseudoaneurysms developed in six of the full root replacements. Freestyle aortic valves have a high rate of acute failure requiring urgent or emergent reintervention in patients 60 years old and younger. This has led our group to shift practice away from their implantation.

Nationally Representative Repeat Transcatheter Aortic Valve Replacement Outcomes: Report From the Centers for Medicare and Medicaid Services

OBJECTIVES

The aim of this study was to examine real-world experience with repeat transcatheter aortic valve replacement (TAVR) in a population-based national database.

BACKGROUND

Repeat TAVR is a growing option in patients requiring reintervention for TAVR. However, large-scale studies with longitudinal follow-up are limited.

METHODS

All Medicare beneficiaries who underwent TAVR from 2012 to 2017 were included. Outcomes included 30-day and longitudinal mortality and major adverse cardiovascular events, defined as death, stroke, pacemaker insertion, major bleeding, acute kidney injury, or cardiac arrest. Outcomes of repeat TAVR were compared with surgical explantation after TAVR (TAVR explantation) in a matched analysis.

RESULTS

Of 133,250 patients who underwent TAVR, 617 (0.46%) underwent subsequent repeat TAVR at a median interval of 154 days (interquartile range: 58-537 days). Mortality at 30 days and 1 year was 6.0% and 22.0%, respectively. Rates of 30-day stroke and pacemaker insertion were 1.8% and 4.2%. Mortality at 30 days was lower in those who underwent their first TAVR during the later era (2015-2017) compared with earlier years (2012-2014) (4.6% vs 8.7%; P = 0.049). Repeat TAVR was associated with lower 30-day mortality compared with a matched group undergoing TAVR explantation (6.2% vs 12.3%; P = 0.05), although 1-year mortality was similar (21.0% vs 20.8%; P = 1.000). The incidence of 30-day major adverse cardiovascular events was higher with TAVR explantation compared with repeat TAVR (risk ratio: 2.92; 95% CI: 1.88-4.99; P ≤ 0.001).

CONCLUSIONS

Repeat TAVR was performed with acceptable 30-day mortality in this high-risk population. Short-term outcomes were superior to surgical explantation, but 1-year outcomes were similar. Repeat TAVR will likely be an important option for aortic valve reintervention after TAVR.

Balloon Expandable Transcatheter Aortic Valve Implantation in Failing Self-Expandable Transcatheter Valve in Degenerated Surgical Bioprosthesis: Valve-in-Valve-in-Valve Implantation for the Treatment of Early Degenerative Prosthetic Insufficiency

Background: Transcatheter aortic valve implantation (TAVI) has emerged as the standard of care for patients with severe aortic stenosis who are at high surgical risk. However, transcatheter valves can degenerate, and redo TAVI has been reported after surgical aortic valve implantation and post initial TAVI.

Case Report: We describe the case of a 70-year-old male who presented with decompensated heart failure secondary to severe prosthetic valve insufficiency. The patient had a history of distant triple coronary artery bypass surgery in 2004, surgical ascending aortic aneurysm repair and stentless aortic valve replacement in 2012, and transcatheter CoreValve (Medtronic) implantation in 2015 for the failing stentless aortic valve. In 2019, the patient presented with heart failure symptoms. A 29-mm SAPIEN 3 valve (Edwards Lifesciences) was implanted for the third time (valve-in-valve-in-valve) with excellent clinical and echocardiographic results and no evidence of coronary obstruction.

Conclusion: Early (<5 years) bioprosthetic valve insufficiency after initial valve-in-valve implantation can be successfully treated with a second TAVI.

A case report of open-aorta, direct transcatheter valve-in-valve implantation: an innovative approach to manage the hazard of coronary flow compromise in transcatheter aortic valve re-interventions

Background

Coronary flow compromise is a significant risk of transcatheter aortic valve therapy. Warranting preservation of coronary flow is even more challenging with transcatheter aortic valve re-intervention since the implantation of a transcatheter valve within a degenerated bioprosthetic or transcatheter valve increases significantly this hazard.

Case summary

We present a case of heart failure secondary to transcatheter aortic valve degeneration requiring a transcatheter aortic valve re-intervention. Pre-operative imaging studies demonstrated a high risk for iatrogenic coronary flow impairment. The patient underwent a successful surgical removal of the prosthetic valve leaflets followed by direct transcatheter aortic valve implantation.

Conclusion

We reviewed the literature on the approach to difficult coronaries in transcatheter aortic valve therapy, and we describe an innovative hybrid approach that may represent a viable alternative in cases where catheter techniques of coronary flow preservation are not applicable.

First-in Human Implantation of a Novel Biologic Valved Conduit for Aortic Root Replacement

Aortic root replacement is a complex procedure. Recently, the Konect Resilia aortic valved conduit® (Edwards Lifesciences), the first prefabricated biologic valved conduit available in the United States of America, was approved for use. Here we report the initial series of three patients representing the first-in-human implantation of the novel Konect biobentall. The conduit was implanted in both supra-annular and intra-annular positions, and the unique design of the sewing ring offers several advantages. The Konect biobentall streamlines the process of root replacement and may represent an improvement in terms of ease-of-implantation and durability.

Valve-in-valve transcatheter aortic valve replacement versus redo surgical aortic valve replacement: A systematic review and meta-analysis

BACKGROUND/AIM

With the growing contemporary use of bioprosthetic valves, whose limited long-term durability has been well-documented, an increase in the need for reintervention is expected. We perform a meta-analysis to compare the current standard of care, redo surgical aortic valve replacement (Redo SAVR) with the less invasive alternative, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) for treating structural valve deterioration.

METHODS

After a comprehensive literature search, studies comparing ViV TAVR to Redo SAVR were pooled to perform a pairwise meta-analysis using the random-effects model. Primary outcomes were 30-day and follow-up mortality.

RESULTS

A total of nine studies including 9127 patients were included. ViV TAVR patients were significantly older (mean difference [MD], 5.82; p = .0002) and more frequently had hypercholesterolemia (59.7 vs. 60.0%; p = .0006), coronary artery disease (16.1 vs. 16.1%; p = .04), periphery artery disease (15.4 vs. 5.7%; p = .004), chronic obstructive pulmonary disease (29.3 vs. 26.2%; p = .04), renal failure (30.2 vs. 24.0%; p = .009), and >1 previous cardiac surgery (23.6 vs. 15.9%; p = .004). Despite this, ViV TAVR was associated with decreased 30-day mortality (OR, 0.56; p < .0001). Conversely, Redo SAVR had lower 30-day paravalvular leak (OR, 6.82; p = .04), severe patient-prosthesis mismatch (OR, 3.77; p < .0001), and postoperative aortic valve gradients (MD, 5.37; p < .0001). There was no difference in follow-up mortality (HR, 1.02; p = .86).

CONCLUSIONS

Despite having patients with an increased baseline risk, ViV TAVR was associated with lower 30-day mortality, while Redo SAVR had lower paravalvular leak, severe patient-prosthesis mismatch, and postoperative gradients. Although ViV TAVR remains a feasible treatment option in high-risk patients, randomized trials are necessary to elucidate its efficacy over Redo SAVR.

How to deal with low-flow low-gradient aortic stenosis and reduced left ventricle ejection fraction: from literature review to tips for clinical practice

Low-flow low-gradient aortic stenosis (LFLG AS) with reduced left ventricle ejection fraction (LVEF) is still a diagnostic and therapeutic challenge. The aim of this paper is to review the latest evidences about the assessment of the valvular disease, usually difficult because of the low-flow status, and the therapeutic options. Special emphasis is given to the available diagnostic tools for the characterization of LFLG AS without functional reserve at stress echocardiography and to the factors that clinicians should evaluate to choose between surgical aortic valve repair, transcatheter aortic valve implantation, or medical therapy.

Device profile of the Inspiris Resilia valve for aortic valve replacement: overview of its safety and efficacy

INTRODUCTION

The Inspiris Resilia tissue valve was recently introduced into clinical practice. This review summarizes the pre-clinical and clinical studies leading to this new bioprosthesis.

AREAS COVERED

The novel Resilia tissue was tested extensively in a large animal model. The clinical use of the tissue started in 2011 with the European Feasibility study, followed by a North-American multi-center study. Since 2017, the Inspiris Resilia valve has been in full commercial use. Further prospective evaluations and registries are ongoing.

EXPERT OPINION

The Inspiris Resilia valve was clinically introduced after pre-clinical tests revealed superiority compared to contemporary therapy such as the Perimount valve. Prospective long-term follow-up studies on Resilia are ongoing since 2011 and reveal no major complications. Full 5-year data show no signs of early degeneration, but longer follow-up is certainly still needed. Several prospective registries are actively monitoring the outcome with the Inspiris Resilia valve now. The novel tissue, designed to mitigate calcification and increase durability, together with the expandable stent, facilitating potential future valve-in-valve (ViV) procedures, are the cutting-edge aspects. Clinical use in younger patients is currently ongoing: their follow-up and outcome will determine the added value of this valve.

The International Society for Minimally Invasive Cardiothoracic Surgery Expert Consensus Statement on Transcatheter and Surgical Aortic Valve Replacement in Low- and Intermediate-Risk Patients: A Meta-Analysis of Randomized and Propensity-Matched Studies

OBJECTIVE

There is an increasing amount of evidence supporting use of transcatheter aortic valve replacement (TAVR) for treatment of aortic stenosis in patients at low or intermediate risk for surgical aortic valve replacement (SAVR). TAVR is now approved for use in all patient cohorts. Despite this, there remains debate about the relative efficacy of TAVR compared with SAVR in lower-risk cohorts and various subgroups of patients. We performed a systematic review and meta-analysis of randomized controlled trials (RCTs) and propensity-matched trials to guide a consensus among expert cardiologists and surgeons.

METHODS

Studies comparing TAVR and SAVR in low- and intermediate-risk patients were identified by a thorough search of the major databases. Mortality, stroke, and other perioperative outcomes were assessed at 30 days and 1 year.

RESULTS

Early mortality was lower in TAVR compared to SAVR in RCTs, but not propensity-matched studies in low-risk cohorts (0.66% vs 1.5%; odds ratio [OR] = 0.44, 95% confidence interval [CI] 0.20 to 0.98, I² = 0%). No difference in mortality between TAVR and SAVR was identified in intermediate-risk patients at early or later time points. Incidence of perioperative stroke in 3 low-risk RCTs was significantly lower in TAVR (0.4%) than SAVR (1.4%; OR = 0.33, 95% CI 0.13 to 0.81, I² = 0%). There was no difference in stroke for intermediate-risk patients between TAVR and SAVR. The expert panel of cardiologists and cardiac surgeons provided recommendations for TAVR and SAVR in various clinical scenarios.

CONCLUSIONS

In RCTs comparing TAVR and SAVR in low-risk patients, early mortality and stroke were lower in TAVR, but did not differ at 1 year. There was no difference in mortality and stroke in intermediate-risk patients. The Multidisciplinary Heart Team must consider individual patient characteristics and preferences when recommending TAVR or SAVR. The decision must consider the long-term management of each patient's aortic valve disease.

Successfully minimal approach ViV-TAVR without angiography in a severe restenosis with renal dysfunction 17 years post-surgical aortic valve replacement: A case report

Severe aortic stenosis (AS) is a major cause of morbidity and mortality in the elderly. Transcatheter aortic valve replacement (TAVR) is an approach in cardiovascular interventional therapy. As we known, most of the candidates for TAVR are suffered from advanced heart dysfunction (New York Heart Association functional class III or IV) and chronic kidney disease. However, contrast-enhanced computed tomography and coronary angiography are necessary for pre-procedures for TAVR. TAVR could have adverse effects on kidney function including contrast-induced acute kidney injury (CI-AKI), which is related to poor prognosis. In a severe recurrent valve stenosis with progressive renal dysfunction, receiving surgical aortic valve replacement (SAVR) using bioprosthetic valve (BV) 17 years ago, we successfully reversed restenosis by performing pre-procedure evaluating and valve-in-valve (ViV) TAVR without angiography. Angiography-free TAVR may be a beneficial approach for patients with aortic restenosis after SAVR complicated with renal dysfunction.

Aortic Paravalvular Leak Repair: Can TAVR Be the Answer?

A 71-year-old male with endocarditis mediated severe paravalvular leak and nonischemic cardiomyopathy underwent percutaneous repair attempts with a closure device followed by valve-in-valve transcatheter aortic replacement procedure. The case was complicated by cardiac arrest requiring hemodynamic support with Impella placement and secondary iatrogenic central aortic insufficiency requiring further intervention. (Level of Difficulty: Beginner.)