https://doi.org/10.1007/s00392-025-02625-4
1Universitäres Herz- und Gefäßzentrum Hamburg Klinik und Poliklinik für Herz- und Gefäßchirurgie Hamburg, Deutschland; 2Universitäres Herz- und Gefäßzentrum Hamburg Klinik für Kardiologie Hamburg, Deutschland; 3Universitäres Herz- und Gefäßzentrum Hamburg Allgemeine und Interventionelle Kardiologie Hamburg, Deutschland
Aortic valve-in-valve (ViV) procedures for treatment of degenerated surgical bioprostheses are an established therapy with proven clinical and hemodynamic efficacy. However, patient profiles and procedural measures and refinements might have changed significantly over the last decade. We herein evaluated changes in patients’ risk profiles, procedural approaches, early outcomes and one-year echocardiographic parameters in aortic ViV procedures over a period of 10 years.
Methods
Between 01/2013 and 12/2023, 256 consecutive patients underwent ViV procedures for degenerated aortic bioprostheses at our center. Baseline, peri- and postprocedural data, 30-day outcomes, and one-year echocardiographic parameters were retrospectively analyzed. Patients were divided into three time periods (group 1: 2013–2016, group 2: 2017–2020, group 3: 2021–2023) and data was compared using chi² test for categorical variables and Kruskal-Wallis test for continuous variables.
Results
Overall, median patient age was 78.0 (IQR 72.2-82.4) years and median EuroSCORE II of 8.1 (IQR 4.9-14.5)%. Durability of surgical prostheses was significantly longer in later time periods (group 1: 8.0 (IQR 6.0-11.0) vs. group 2: 11.0 (8.0-14.3) vs. group 3: 12.0 (9.0-14.0) years; p<0.001). Accordingly, a commonly considered early deteriorating surgical bioprosthesis with externally mounted leaflets presented the highest proportion as index valve in group 1 (34.2% vs. 23.8% vs. 7.8%, p<0.001). Utilization of cerebral protection devices presented with a distinct decline in group 3 (56.2% vs. 68.8% vs. 18.4%, p<0.001). Access proportions changed significantly over time with transfemoral access in 100% of patients in group 3 (75.3% vs. 98.8% vs. 100.0%, p<0.001). Over time significantly more BASILICA procedures were performed (0% vs. 17.5% vs. 19.4%; p<0.001), and rates of valve fracturing steadily increased (0% vs. 6.3% vs. 7.8%, p=0.058). Early outcome parameters such as rates of permanent pacemaker implantation, bleeding, acute kidney injury disabling stroke, 30-day mortality were without significant differences between groups. Device success was high in all groups (67 (91.8%) vs. 74 (92.5%) vs. 101 (98.1%), p=0.123). After one-year follow-up, echocardiographic assessments presented stable hemodynamic results in terms of low mean transvalvular gradients (13 (IQR 9.5-21) vs. 11 (IQR 8.3-12) vs. 9 (IQR 6-16.8) mmHg, p=0.124) and no relevant valvular or paravalvular regurgitation. Symptomatic burden as represented by NYHA classification was low with only three patients (4.8%) in NYHA class ≥ III, without significant differences between groups.
Conclusion
This ten-year study of aortic ViV procedures for degenerated bioprostheses showed significant changes in procedural measures such as transfemoral access, BASILICA procedures and valve fracturing. Additionally, the peak incidence of degenerated Mitroflow prostheses appears to have been reached. Moreover, the impact of randomized controlled trials demonstrating the limited efficacy of cerebral protection devices has influenced clinical practice. Early outcomes such as device success, stroke, and 30-day mortality were excellent with improvement over time, highlighting the procedure's clinical efficacy and safety. One-year echocardiographic follow-up confirmed stable hemodynamic outcomes post aortic ViV implantation.