Redo procedures for degenerated stentless aortic xenografts and the role of valve-in-valve transcatheter techniques

Abstract

Objectives: This study evaluates reinterventions for degenerated stentless aortic xenografts.

Methods: Between 2010 and 2015, 52 consecutive patients (age 72.3 ± 9.7 years, EuroSCORE II 11.1 ± 8.9%) underwent reintervention for failed stentless aortic valves (60% porcine, 40% pericardial, 87% sub-coronary, 81% isolated/combined regurgitation).

Results: Based on age, EuroSCORE II, the presence of pulmonary hypertension, renal failure, a patent internal mammary artery graft and required concomitant procedures, the heart team assigned 25 patients to reoperation and 27 to valve-in-valve transcatheter aortic valve implantation (ViV-TAVI). Valve implantation was successful in all surgical (24% root replacement) and in 24 transcatheter cases (93% trans-femoral, 56% balloon-expandable). Procedural complications were aortic dissection ( n = 1) during reoperation and coronary obstruction ( n = 4), device malpositioning ( n = 3), deployment of >1 valve ( n = 2) and vascular access site complications ( n = 2) during ViV-TAVI. Thirty-day mortality (10%, three ViV-TAVI patients, two surgical patients, P = 1.0) was associated with preoperative renal failure, >1 concomitant procedure, life-threatening bleeding, coronary obstruction and necessity for prolonged circulatory support. ViV-TAVI was beneficial regarding ventilation time, transfusion requirements and the incidence of sepsis. Overall, functional (94% New York Heart Association Class I/II) and echocardiographic results (indexed effective orifice area 0.95 ± 0.27 cm 2 /m 2 , mean transvalvular gradient 14 ± 6.8 mmHg) were favourable. After ViV-TAVI, aortic regurgitation was mild and moderate in two and three patients. One-year survival was 82.3 ± 5.4% and similar after surgery (83.1 ± 7.7%) and ViV-TAVI (81.5 ± 7.5%, P = 0.76).

Conclusions: Reinterventions for degenerated stentless aortic valves are challenging. Although ViV-TAVI is appropriate in high-risk patients, limitations and potential complications must be considered. Redo surgery has its place in low-risk patients and if concomitant procedures are required.

Keywords: Reoperation; Stentless aortic xenograft; Valve-in-valve transcatheter aortic valve implantation.