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Mean aortic valve gradients have been shown to be elevated after transcatheter aortic valve (TAV) implantation in surgical bioprostheses (TAV-in-SAV). However, no data exists on valve function after placement of a second TAV in a failed TAV (TAV-in-TAV). We compared both procedures performed in our institution between 10/2007 and 02/2016.
92 consecutive patients out of a total of 1595 patients were identified who underwent TAV-in-SAV (n=61; age 67±8 years, male 64%; STS score 5.2%±3.3%) or TAV-in-TAV (n=31; age 79±7 years, male 58%; STS score 4.6%±3%). The type of TAV was similarly distributed in TAV-in-SAV and TAV-in-TAV (self-/balloon-expandable valves [%] 61/39 vs. 65/35), as was choice of access site (transfemoral/transapical/other [%] 59/34/7 vs. 77/20/3). The reason for TAV implantation was mainly stenosis in the TAV-in-SAV group (77% stenosis/13% regurgitation/10% combined,) whereas it was exclusively regurgitation in the TAV-in-TAV group. Echocardiographically assessed left ventricular outflow tracts as index for annulus dimensions were 21±2 mm in both groups (p=0.255). Perioperative patient data were analyzed from our prospectively collected, institutional database.
Differences in aortic valve gradients, aortic valve area and aortic regurgitation at discharge after TAV-in-SAV vs. TAV-in-TAV are shown in the Table. Major intraprocedural complications (tamponade, annulus rupture, myocardial infarction) occurred in neither group. 30-day mortality was 3.3% (n=2) in the TAV-in-SAV and 9.7% (n=3) in the TAV-in-TAV group (p=0.201).
|EOA (cm2)||1.23 ± 0.33||1.59 ± 0.35||<0.001*|
|Peak Gradient (mmHg)||33 ± 14||21 ± 8||<0.001*|
|Mean Gradient (mmHg)||19 ± 8||12 ± 4||<0.001*|
|AR (0-3)**||0.25 ± 0.44||1.0 ± 0.7||<0.001*|
|LVEF (%) ***||0.915|
|* p<0.05 significant;** AR=Aortic regurgitation (0=none/trace, 1=mild, 2=moderate, 3=severe); *** LVEF=Left ventricular ejection fraction: good >50%, moderate 35-50%, poor <35%|
Indications for TAV-in-TAV differ from those for TAV-in-SAV. TAV-in-TAV results in significantly lower gradients and larger effective orifice areas (EOA). Accordingly, failed trancatheter aortic valves may be treated with TAV-in-TAV in the future.
STRUCTURAL: Valvular Disease: Aortic