Valve-in-valve In Failing Homografts: Early Experience And Outcomes
Michal A. Szlapka, Duc Thinh Pham, Andrei Churyla, James Flaherty, Charles Davidson, Mark J. Ricciardi, Ranya N. Sweis, Jane Kruse, Adin-Cristian Andrei, Christopher S. Malaisrie.
Northwestern Memorial Hospital, Chicago, IL, USA.
Objectives Transcatheter aortic valve replacement (TAVR) valve-in-valve (V-i-V) for homograft structural valve degeneration (SVD) is feasible, but should be implemented with caution, as the predominant homograft-SVD mechanism is regurgitation. We present our concept of distributed, ‘aortic-to-ventricular' in-homograft fixation and outcomes of TAVR ViV for homograft versus bio-prostheses-SVD.
Methods
Between 2015 and 2017, 41 patients underwent TAVR ViV for the aortic valve prosthesis-SVD. Of them, 33 patients presented with degenerated bio-prostheses (TAVR-BP group) and 8 with homografts (TAVR-H group). The Valve Academic Research Consortium (VARC) criteria were used for reporting purposes.
Results
Patients in TAVR-BP group were older (72.5±15.1 yrs. vs. 50.8±16.7 yrs. p<.001) and 94% of them had prosthetic stenosis, compared to TAVR-H group (p=0.002), while 88% of TAVR-H patients had aortic regurgitation (p=<.001). The STS score was 5.7±3.7% in TAVR-BP vs. 1.9±0.6% in TAVR-H group, p=0.006.
TAVR-H patients received: Sapien-3 (6), Sapien-XT (1) and CoreValve (1) devices. Deep, 30%-40% ventricular fixation was attempted to anchor the prosthesis on the homograft suture line.
In the entire cohort, there was zero 30-day mortality and stroke. One TAVR-BP patient experienced distal prosthesis migration and Type-B aortic dissection, treated with immediate transcatheter endovascular aortic repair. First-attempt device implantation was successful in 26 (78%) TAVR-BP and in 7 (87%) TAVR-H patients. In 3 (9%) TAVR-BP individuals a second device was used. No patient required pacemaker implantation.
In 2 TAVR-H patients with preoperative homograft regurgitation, a moderate paravalvular leak (PVL) occurred in mid-term follow-up. In both of them, extensive, 60%-ventricular fixation led to mismatch between fixation points and homograft suture line. Recent imaging revealed progressive device migration in one patient.
There were no differences in perioperative (19.5±8.9 mm Hg vs. 19.1±5.5 mm Hg, p=0.92) and mid-term follow-up transvalvular gradients (18.2±7.5 mm Hg vs. 17.9±5.0 mm Hg, p=0.91) between groups.
Conclusions
Aortic regurgitation was the predominant homograft-SVD mechanism. However, lack of calcification did not cause perioperative prosthesis migration. TAVR ViV in regurgitant homograft can be safely implanted provided that the prosthesis fixation points match the homograft suture line. Precise, 30%-40% ventricular device positioning is crucial for procedural success and avoidance of PVL/late prosthesis migration. 
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