TAVR for Valve-In-Valve. Brian O Neill Assistant Professor of Medicine Department of Medicine, Section of Cardiology

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1 TAVR for Valve-In-Valve Brian O Neill Assistant Professor of Medicine Department of Medicine, Section of Cardiology Temple Hearth and Vascular Institute

2 Disclosures: Consultant: Cardiac Assist

3 TAVR for Valve-In-Valve Background TAVR is now an accepted treatment for high-risk patients with severe AS In high-risk patients, compared to medical therapy TAVR reduces mortality and has similar safety and efficacy compared to SAVR at 2 years and beyond As of 2013 > 50,000 procedures have been done world-wide The use of bioprosthetic heart valves has increased in the past decade

4 TAVR for Valve-In-Valve Background Bioprosthetic valves obviate the need for OAC Rx and the risk of bleeding, particularly in the elderly Bioprosthetic valves are still subject to inevitable structural failure over the long-term Causes of bioprosthetic valve failure leaflet degeneration and calcification, less commonly pannus formation and thrombosis

5 TAVR for Valve-In-Valve Risks for Re-do Surgical AVR (5-11.5%) Increased risk compared to the index procedure per se Prior CABS (LIMA in particular) Porcelain aorta Increased age Need for aortic root enlargement Co-Morbidities Renal impairment Pulmonary disease Cognitive impairment Functional Class, frailty Decreased EF Need for concomitant CABS at time of re-do Jones et al. Repeat heart surgery: risk factors for operative mortality. J Thorac Cardiovasc Surg;2001;122: Potter et al. Operative risk of reoperative aortic valve replacement. J Thorac Cardiovasc Surg; 2005;129: Jamieson WR et al. Reoperation for bioprosthetic aortic structure failure-risk assessment. Eur J Cardiothorac Surg; 2003; 24:873-78

6 Key Issues and Considerations for Valve-In-Valve MDT approach to the procedure as with any TAVR Valve sizing Positioning and deployment Stentless valves make correct positioning and anchoring technically challenging TEE and Heart Navigator may be helpful

7 Bioprosthetic Surgical Valves Stented Bovine Pericardial Stented Porcine Aortic Stentless Bioprosthetic Mylotte et al. Heart 2013;960-67

8 Dimension Measurements A=Outer base ring diameter B= Inner base ring diameter C= Height D=Outer sewing ring diameter Mylotte et al. Heart 2013; (Maximum available diameter for TAVI) (determines the maximum size of the valve at implanation)

9 Bench-top Testing for Valve-In-Valve Milburn et al. Clin Res Cardiol 2014;103:417-29

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11 Transcatheter Aortic Valve Replacement for Degenerative Bioprosthetic Surgical Valves Results from the Global Valve-in-Valve Registry 202 Patients with Degenerated Bioprosthetic Valves 38 centers, 77±10.4 years, 52% male Bioprosthetic failure AS (42%), AR (34%), AS/AR (24%) Implanted devices CoreValve (124), Edwards SAPIEN (78) Procedural success 93.1% Adverse outcomes Device malposition 15.3% Ostial obstruction 3.5% Dvir et al. Circulation 2012;126:

12 Transcatheter Aortic Valve Replacement for Degenerative Bioprosthetic Surgical Valves Results from the Global Valve-in-Valve Registry Dvir et al. Circulation 2012;126:

13 Transcatheter Aortic Valve Replacement for Degenerative Bioprosthetic Surgical Valves Results from the Global Valve-in-Valve Registry Dvir et al. Circulation 2012;126:

14 Transcatheter Aortic Valve Replacement for Degenerative Bioprosthetic Surgical Valves Results from the Global Valve-in-Valve Registry Dvir et al. Circulation 2012;126:

15 Transcatheter Aortic Valve Replacement for Degenerative Bioprosthetic Surgical Valves Results from the Global Valve-in-Valve Registry Dvir et al. Circulation 2012;126:

16 Transcatheter Aortic Valve Replacement for Degenerative Bioprosthetic Surgical Valves Results from the Global Valve-in-Valve Registry Dvir et al. Circulation 2012;126:

17 Transcatheter Aortic Valve Replacement for Degenerative Bioprosthetic Surgical Valves Results from the Global Valve-in-Valve Registry Dvir et al. Circulation 2012;126:

18 Transcatheter Aortic Valve Replacement for Degenerative Bioprosthetic Surgical Valves Results from the Global Valve-in-Valve Registry Implications for Cardiac Surgery TAVR for pts with failed bioprostheticvalves with markedly elevated risk for reoperation selection of valve class (biological much more than mechanical) and valve type (with minimal risk for ostial coronary obstruction)during surgery And performance of root enlargement in small aortic roots Not enough data to justify VIV instead of reoperation in most high risk patients Nevertheless, VIV is an acceptable alternative is those patients who have no option VIV practice may also affect the selection of valve type during SAVR - A less invasive approach for failed bioprosthesis could be an argument for bioprosthesis in younger patients undergoing SAVR. Surgical valves with increased risk of coronary ostial obstruction should probably be used less frequently Dvir et al. Circulation 2012;126: