Valve in Valve: που βρισκόμαστε

σήμερα?

Κ. Αγγέλη

Αν.Καθηγ. Καρδιολογίας

Α. Πανεπ. Καρδιολογική Κλινική

Case 1

• 71 year-old man admitted due to progressively increasing dyspnea (NYHA class III)

• Background:

• Severe degenerative MR secondary to ruptured tendinous cord of the anterior mitral leaflet

• Severe AR

• 2007: Surgery with complex MV reconstruction

• Annuloplasty with a 25-mm circular flexible Duran ring (Medtronic, Minneapolis, Minnesota), implantation

of the ruptured tendinous cord into the anterior papillary muscle, and placement of new synthetic chordae

tendineae.

• A prosthetic metallic aortic valve (ATS Open Pivot Heart Valve 25 mm, ATS Medical, Inc. Minneapolis,

Minnesota).

Normocytic anemia accompanied by elevated indirect bilirubin and LDH levels,

suggestive of hemolytic anemia

TTE

Case 2

• 71 years-old female admitted with heart failure symptoms (NYHA IV)

• Previous Interventions:

- 06/2016: Surgical tricuspid valve replacement with a 27-mm Epic bioprosthetic valve (St Jude Medical, Inc, St Paul, Minnesota) and implantation of a bipolar

pacemaker lead for future use

- 05/2012: Surgical mitral valve replacement with a mechanical valve

• Other Medical History:

- Atrial fibrillation, DM type II

- Pleurodesis for persistent pleural effusion

• Meds : acenocoumarol, diuretics, antidiabetic treatment

71 years-old female admitted with heart failure symptoms (NYHA IV), surgical TV replacement with a 27-mm Epic

bioprosthetic valve (06/2016), surgical MV replacement with a mechanical valve (05/2012)

71 years-old female admitted with heart failure symptoms (NYHA IV), surgical TV replacement with a 27-mm Epic

bioprosthetic valve (06/2016), surgical MV replacement with a mechanical valve (05/2012)

• 85.000 heart valve prostheses are implanted in the United States each yearand a total 275.000 worldwide.

• The use of bioprosthetic aortic valve replacement increased from 26.7% in1998 to 50.2% in 2005.

• The major shift in the use of surgical bioprostheses, combined with theirshorter durability and the increasing life expectancy of an aging population,is expected to translate into a major increase in the incidence of patientswith surgical valve failure in the coming years.

Modes of Bioprosthetic Valve Failure

Singh et al, J Am Coll Cardiol 2019;73:1707–18

• The mechanism of aortic bioprosthesis dysfunction are equally distributed

as predominantely stenostic, regurgitatnt, or mixed, with larger rate of

stenotic dysfunction among stented and smaller (<21mm) valves, and a

predominant regurgitatnt mechanism among stemless valves. In mitral

biprostheses, regurgitation is the predominant mechanism of valve

dysfunction (49%), followed by stenosis (22%) and combined mechanisms

(30%).

Management of prosthetic valve dysfunction

ESC Guidelines on VHD 2017, European Heart Journal (2017) 38, 2739–2791

Stented Bioprostheses

Stentless Bioprostheses

Each valve is unique!!

High Gradients

Importance of true ID

• To choose the right size of TAVI device

• To avoid PP mismatch and valve dysfunction

Label size does not mean same ID!!

True ID = Stent ID- reduction due to leaflet tissue

Oversizing is bad

Incomplete expansion

Uneven expansion

Russian Doll effect

Ideal Position : Reference Level

Sewing ring

With Reference to the Neo-annulus = Sewing ring Where is the sewing ring?

Sewing ring marker

Stent frame marker

No marker

High Gradients

Lower gradient with supra-annular leaflets

Dvir et al. JAMA 2014; 312-162-70

High Gradients

High implant give lowest gradient

Simonato et al. Circ Cardiovasc Interv 2015

High implantation results in larger EOA!

Simonato et al. VIVID Registry. Eurointervention 2016

Effect of PPM

Pibarot P, et al. VIVID Registry JACC 2018

Elevated gradients (>20mmHg) and mortality

Severe PPM of the surgical valve is associated with higher mortality after ViV

Risk of Coronary obstruction

Importance of true ID

Function of

• Smaller anatomy

• Narrow sinuses

• Oversizing- Stent post deflection

• Valves with leaflet outside the stent

Low High

Wide sinuses

No or low risk

Narrow Sinuses

Higher risk

Meta-analysis of ViV-TAVR vs Redo AV surgery

• Meta-analysis of retrospective or prospective studies that reported direct comparison of outcomes after ViV-TAVR

or redo-SAVR in patients with failed aortic bioprosthetic valves

• 4 studies with 489 patients (227 of underwent ViV-TAVR and 262 underwent redo-SAVR)

• The incidence of stroke, MI, and AKI requiring dialysis were similar.

• The rate of PPM was significantly lower in the ViV-TAVR.

30-day mortality was similar in 2 groups despite the higher operative risk in the ViV-TAVI cohort

Neupane et al, Am J Cardiol. 2018 Jun 15;121(12):1593-1600

Meta-analysis of ViV-TAVR vs Redo AV surgery

• Retrospective or prospective studies that reported direct comparison of outcomes after ViV TAVR or redo-SAVR in

patients with failed aortic bioprosthetic valves

• 6 studies with 498 patients (254 of underwent ViV-TAVR vs. 244 underwent redo-SAVR)

• Patients in the VIV-TAVI group were significantly older and had undergone prior CABG more frequently than those

in the redo SAVR groupNo statistically significant differences all cause mortality

in early (in hospital or 30 days) and midterm (180 days – 3 years)

Takagi et al, Thorac Cardiovasc Surg. 2019 Jun;67(4):243-250

Meta-analysis of ViV-TAVR vs Redo AV surgery

• Six observational studies with 594 patients (255 underwent ViV-TAVR vs. 339 underwent redo-SAVR)

No statistically significant differences in procedural, 30-day, and 1 year mortality rates

Naluri et al, J Interv Cardiol. 2018 Oct;31(5):661-671

Procedural mortality

1 year mortality

The PARTNER II Trial:

Valve-in-Valve TAVR Registry

Webb JG et al. JACC 2017;69:2253-62

In high-risk patients, TAVR for bioprosthetic aortic valve failure is associated with relatively low mortality and complication

rates, improved hemodynamics, and excellent functional and quality-of-life outcomes at 1 year.

MITRAL VALVE

Paradis, J-.M. et al. J Am Coll Cardiol. 2015; 66(18):2019–37.

The ideal prosthetic valve for MV disease

Maisano et al, Eur Heart J. 2015 Jul 7;36(26):1651-9

Challenges For Transcatheter MV prosthesis Development

Regueiro, A. et al. J Am Coll Cardiol. 2017;69(17):2175–92.

Access during mitral ViV /ViR procedures

Predicting LVOTO in Transcatheter MV Implantation:

Concept of the Neo-LVOT

Blanke et al, JACC Cardiovasc Imaging. 2017 Apr;10(4):482-485

During surgical MVR, the anterior mitral valve leaflet is often removed to mitigate LVOTO!!

Blanke et al, JACC Cardiovasc Imaging. 2017 Apr;10(4):482-485

Workflow:

Concept of the Neo-LVOT

TRICUSPID –PULMONARY POSITION

Available valves

Melody valve - Medtronic Sapien 3 and Sapien XT - Edwards

Eicken et al, Cardiovasc Diagn Ther 2018;8(6):765-770

McElinney et al, Circulation 2016

152 patients

53 centers worldwide

Median age: 40 years

Bioprosthetic TV dysfunction

71% of patients in NYHA class III or

IV

Melody (n=94) or Sapien

(n=58) TVIV implantation

Median follow-up:13.3 months

VIVID Registry

Transcatheter tricuspid ViV implantation

VIVID Registry

Transcatheter tricuspid ViV implantation

McElhinney DB et al, Circulation. 2016 Apr 19;133(16):1582-93

Estimated probability of survival MG across TV before and after ViV

implantation

Complex CHD

RVOT disorders

Available valves

Seong-Ho Kim et al, Korean J Pediatr 2017;60(8):237244

For native RVOT

diameters

>26-27mm

Challenging

procedure

E. Sabbagk et al, Catheter Cardiovasc Interv. 2018 Jan 23.

Assessment of adequacy of valve anchoring, risk of under-expansion and LVOT obstruction

Valve anchoring – measuring the circumferential extend of MAC, reported as a percentage of the mitral annulus, as well as the location of the calcification.

Valve anchoring - measuring the surface area of the virtual valve in direct contact with the digital mitral annular calcification.

Risk of underexpansion - measuring the volume of calcium overlap.

LVOTO - visual assessment of the 3D digital LVOT model in systole with the digital valve inserted.

Paravalvular leak assessment

3D models simulated the location of PVL

E. Sabbagk et al, Catheter Cardiovasc Interv. 2018 Jan 23.

3D models were similar to the findings on

post procedural imaging.Visual inspection of any gaps between the virtual Sapien

valve, mitral annulus and mitral leaflets.

Conclusions