Outcome of 100 Patients treated with Valve-in-Valve Transcatheter Aortic Valve Replacement at a High Volume Center

Michael Paukovitsch (Ulm)1, B. Dilaver (Ulm)1, D. Felbel (Ulm)1, J. Mörike (Ulm)1, M. Krohn-Grimberghe (Ulm)1, D. Buckert (Ulm)1, W. Rottbauer (Ulm)1, B. Gonska (Ulm)1

1Universitätsklinikum Ulm Klinik für Innere Medizin II Ulm, Deutschland


Aim: Due to high surgical risk of re-do aortic valve replacement in patients with failed bioprosthetic valves, valve-in-valve transcatheter aortic valve replacement is increasingly used instead.

We report on procedural results and early outcome of valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) at our high-volume tertiary heart center. 

Methods & Results: All consecutive patients treated with ViV-TAVR at our tertiary heart center between January 2014 and December 2022 were retrospectively analyzed. 

100 elderly (78.5 years, IQR 70.0-84.0) patients (42% females) with an average Society of Thoracic Surgeons (STS) score for mortality of 5.1% (IQR 2.6-8.6%) underwent transfemoral ViV-TAVR. 88% received TAVR in degenerated surgical bioprostheses, 12% in degenerated transcatheter bioprostheses.  The vast majority (77%) of patients was highly symptomatic with NYHA functional class III/IV class. 

Stenosis was the main mechanism of bioprosthetic valve failure (69%), whereas severe regurgitation was the leading cause in 31%. Average durability of bioprosthetic valves was 9 years (IQR 6.0-12.8). In patients with stenosis, echocardiographic preprocedural mean and peak gradients were 40.8±16.2 and 69.0±26.4mmHg, respectively. 

In 62 patients a self-expandable Medtronic valve (CoreValve/Evolut) was implanted, whereas 36 received the balloon-expandable Edwards Sapien 3 valve, 2 patients were treated with the mechanically expanded Boston Lotus Edge valve. Due to valve migration implantation of a second device was necessary in one patient. There was no case of coronary obstruction. 

Postprocedural mean and peak gradients decreased significantly (both p<0.01) to 19.3±10.1

and 32.9±16.8mmHg, respectively. 99% had none/trace or mild postprocedural aortic regurgitation.

In-hospital device success was achieved in 62% of patients. 38% were classified as non-device success driven by elevated echocardiographic postprocedural mean gradients (≥20mmHg) in all but one of these patients. 30-day all-cause mortality rate was 4%. 

In multivariate logistic regression analysis small (<20mm) native prosthesis internal diameter (OR 2.6, 95% CI 1.05-6.4, p=0.04) and design of the degenerated bioprosthesis (stented) (OR 8.4, 95% CI 1.02-68.7, p=0.048) were found to independently predict elevated mean gradients ≥20mmHg at discharge. 

Conclusion: ViV-TAVR for treatment of degenerated bioprostheses is a safe procedure improving aortic valve function. However, device success is lower compared to TAVR in native aortic valve disease, mainly due to postprocedural remaining elevated gradients. Predictors of elevated gradients were small internal diameter and stented design of the degenerated bioprosthesis. 

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