Optimizing hemodynamics of transcatheter aortic valve-in-valve implantation in 19-mm surgical aortic prostheses.

OBJECTIVE: To demonstrate the feasibility of achieving good hemodynamic results with valve-in-valve transcatheter aortic valve replacement (ViV TAVR) for degenerated 19 mm surgical bioprosthetic valves.

BACKGROUND: Considerable controversy exists regarding ViV TAVR within 19mm surgical prostheses due to concerns of elevated valve gradients and mortality.

METHODS: Among all patient undergoing ViV TAVR between 7/2016 and 4/2017 for symptomatic severe bioprosthetic aortic stenosis (AS), five had a 19 mm surgical valve in place and were included in this publication. None of the patients had patient-prosthesis mismatch. Aggressive post-dilation was performed in four out of five cases using a special technique we describe below.

RESULTS: In all cases, mean aortic valve (AV) gradients significantly improved post-ViV TAVR, particularly after post-dilation. Interestingly, high pressure post-dilation of the ViV resulted in an increase in the diameter of surgical valve stent frame dimensions in nearly all patients who underwent post-dilation.

CONCLUSIONS: Good hemodynamic outcome is possible with aggressive post-dilation in patients with 19 mm failed surgical bioprostheses. High-risk patients with 19 mm failed surgical prostheses who do not otherwise have viable surgical options should be considered for ViV TAVR.