FUNDAMENTALS:

Bioprosthetic structural valve deterioration (SVD) is commonly diagnosed after an average interval of 7 to 10 years post-surgery, and surgical aortic valve replacement remains the most prevalent treatment in this condition. However, a significant proportion of affected patients (pts) are elderly with comorbidities and a higher surgical risk profile, making them ineligible for a redo surgery. In this scenario, aortic "valve in valve" (ViV) emerges as an alternative treatment of SVD.

OBJECTIVE:

We aimed to describe the clinical and hemodynamic outcomes after aortic ViV in consecutive patients.

METHODS:

Retrospective, single-center study involving all consecutive patients (pts) undergoing aortic ViV. Clinical and echocardiographic outcomes were defined according to the VARC-III criteria.

RESULTS:

From December 2022 to April 2024, 22 consecutive pts underwent aortic ViV. Mean age was 73.6 ± 7.6 years, 50% were female, and mean STS score was 6.9 ± 6.7%. Two pts had undergone more than one cardiac surgery (CS) and five (22%) underwent concomitant coronary bypass surgery. The most common cause of SVD was insufficiency (73%), and six (27%) pts had SVD with stenosis. In four (18.2%) pts, the previous surgical valves had no fluoroscopic markers. A coronary height of less than 12 mm was found in 72% of pts, and 6 (27.3%) cases had a valve-to-coronary distance (VTC) of less than 4 mm. Myval (Meril Lifesciences), Evolut (Medtronic) and Sapien 3 (Edwards Lifesciences) transcatheter heart valves (THV) were used in 54.6%, 36.3% and 9.4%, respectively. All THV were implanted with no pre-dilation, and post-dilation was needed in 59% of pts. Leaflet modification (BASILICA) was performed in one case, and chimney stent technique was required in two pts. There were no cases of valve embolization, stroke, major vascular or hemorrhagic events. One death (4.5%) occurred due to coronary obstruction from sinus sequestration. Mean gradient after the procedure was 6.5 ± 4.9 mmHg, and the effectiveorifice area was 1.2 ± 0.24 cm2.

CONCLUSION:

In our experience, good clinical and haemodynamic outomes were observed after aortic ViV procedures in older, intermediate surgical risk patients. However, predicted risk factors for coronary occlusion were commonly found in these pts, and additional techniques had to be implemented to prevent this serious and potentially fatal complication.