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The Valve-in-Valve Procedure - Does Patient Prosthesis Mismatch Matter?
Philipp Kiefer, Alexandro Hoyer, Thilo Noack, Eric Nerger, Axel Linke, Joerg Seeburger, Friedrich W. Mohr, David Holzhey.
Heart Center Leipzig, Leipzig, Germany.

OBJECTIVE: Transcatheter aortic valve implantation used as a Valve-in-Valve (V-i-V) procedure is well established. We herein investigate the role of the surgical valve sizes and their initial gradients compared to the hemodynamic functions after V-i-V.
METHODS: The V-i-V procedure was performed in 99 patients in our institution. Out of this cohort 62 patients were identified with full hemodynamic assessment after initial surgical aortic valve implantation (SAVR) and after transcatheter V-i-V implantation. Patient-Prosthesis-Mismatch (PPM) was calculated within 4 groups related to initial surgical valve size (19, 21, 23,≥25). Mean age was 77.4±7.1 years (59% male) with a logEuroScore of 27.5±16.4%. Transfemoral, transapical and transaortal access was used in 45 (73%), 14 (22%) and 3 (5%) patients, respectively. We used 30 Sapien valves (Edwards Lifesciences, Irvine, CA), 30 CoreValve (Medtronic Inc., MN, USA) and 2 others.
RESULTS: ViV-procedure was successfull in 100% (n=62) of the cases with a mean procedural time of 66.1±43.5 min. 30-day, 1year and 2 year mortality was 6.4%, 8.1% and 12.9% respectively. Group 1 (size 19, n=1) showed severe PPM. Group 2 (size 21, n=14) showed moderate PPM in 11 (78%) patients but with no significant changes in hemodynamics after ViV compared to initial SAVR (mean Pmax: 27>24 mmHg,p=0.29). Group 3 (size 23, n=29) showed moderate PPM in 22 (76%) patients with significant changes in hemodynamics after ViV compared to initial SAVR (mean Pmax 42>22 mmHg, p=0,02). No PPM was detected in Group 4 (size ≥25, n=18), but hemodynamic improvment after ViV compared to SAVR (mean Pmax 20>22 mmHg,p=0.65).
CONCLUSIONS: Transcatheter V-i-V procedure is associated with good results. PPM and the initial surgical valve size have a significant influence on hemodynamic function after ViV.

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