Transcatheter Valve-in-Valve Implantation in Degenerated Stentless Aortic Xenografts

Objectives: Transcatheter aortic valve implantation (TAVI) after stentless valve replacement is discussed controversially. Implantation can be challenging due to missing radiopaque marking of the valve plane to fluoroscopically guide implantation depth. Moreover as valve migration was observed early postoperatively, there is concern about sufficient resistance of stentless tissue. We investigated feasibility and success in that scenario.

Methods: From 2011 to 2018, nineteen patients [pts] (mean age 72.8 ± 10 years; 16 males; logistic EuroSCORE I 33 ± 16) underwent reintervention of degenerated stentless aortic valves (mean diameter: 27±2 mm).Indication for reoperation was combined aortic valve disease (1/19; 5%) or pure aortic regurgitation [AR] (18/19, 95%). Two pts underwent emergent surgery (2/19; 11%). 10 /19 pts (53%) had additional coronary bypass surgery previously. Mean time from initial operation was 11.6±3.7 years.

Results: Access path was transfemoral in 10/19 (53%)and transapical in 9/19 (47%) pts. Implanted valve prostheses were balloon-expandable (Edwards SAPIEN; n = 18: 23 mm, n = 2; 26 mm, n = 2, 29 mm, n = 14); or self-expanding devices (Symetis Acurate NeoL; n = 1). Procedural success rate was 100%. Two pts needed additional conventional surgery due to main stem obstruction (n = 1) and severe mitral regurgitation (n = 1) after the TAVI procedure. There was no device malpositioning or deployment of more than one valve.

Periprocedural complication rate was 5/19 (26%): AV block with the need of pacemaker implantation (n = 2), retroperitoneal hematoma after transfemoral access (n = 1), thromboembolic cerebral event (n = 1), temporary hemodialysis (n = 1).

In the follow-up, two pts developed endocarditis, 1 week and 8 months postoperatively. They were treated by conservative antibiotic therapy (n = 1) and mechanical valve replacement Gr. 27 mm (n = 1). Intraoperative TEE showed a completely competent valve in 16/19 (84%); paravalvular leakage with resulting AR grade 1 in 3/19 (16%) pts. Thirty-day mortality was 4/19 (21%). Causes of death were multiorgan failure (n = 1), coronary obstruction (n = 1), major neurologic event (n =1), and gastrointestinal bleeding (n = 1). In postoperative TTE, within 5 days after the procedure, results remained unchanged to the intraoperative findings. Mean transvalvular gradient was 8.5 ±3.9 mm Hg.

Conclusions: TAVI after stentless aortic valve replacement leads to excellent functional results with acceptable morbidity and mortality.