Valve-in-valve In Degenerated Xenograft And Homograft With Regurgitation
Gry Dahle, Lars Aaberge, Jon Thomas Offstad, Kjell Arne Rein.
Rikshospitalet, OUS, Oslo, Norway.
Valve-in-valve (VIV) is an alternative to redo open heart surgery in patients with degenerated bioprostheses. Special challenges are for the stentless and regurgitant xenograft and homograft regarding the selection and sizing of the transcatheter valve (THV) as the surgical bioprostheses tend to dilate. The lack of calcium landmarks as well as contrast disappearance may entail a demanding implantation.
Sizing was done by CT reconstruction. All procedures but one was performed with a transapical approach. Fast pacing was done to retain the contrast in the aortic root. One procedure was an emergency case, hence no CT scan could be provided.
Seven patients, three male mean age 56 (27-87) years were treated (2012-2016), mean 10.1 (6-14) years after first operation. Ratio homograft/xenograft 4:3, all with aortic regurgitation, mean given size was 25.3 mm. The transcatheter valves used were; self-expandable: 1, self-expandable with control arms: 2, self-expandable with stabilization arches: 1, balloon expandable: 3, mean size 26.5mm. The implantation success was 86%. Two patients had a second catheter valve implanted. There were no peri-procedural death, cerebral stroke, coronary obstruction or new pacemaker implantation. Mean observation time was 20 (1-40) months, no early mortality, total survival 83%. One patient had more than trace PVL. Mean gradient was 14 mmHg, at latest follow up 23mmHg.
The balloon expandable valve showed good hemodynamics, but was difficult to place, and a second valve implantation was needed in two patients. The self-expandable valve with control arms was easy to deploy, but has later on demonstrated high gradients (withdrawn from market). The self-expandable valve with stabilization arches was easy to deploy and has shown good hemodynamics. We had no access to the CE approved self-expandable valve with feelers in the beginning of our THV program.
Repositionable and re-sheathable THV with tactile feedback may be preferred in the VIV procedure for xenograft and homograft, though the current lack of bigger sizes is a limitation. CT reconstruction for annulus sizing is mandatory.
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