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Planning key to success of valve-in-valve TAVR for failing stentless valves
SAN FRANCISCO — Patients with failing stentless bioprostheses who undergo valve-in-valve transcatheter aortic valve replacement appear be at higher risk for early death than those with failing stented valves, but the trend becomes less apparent over time, according to a presentation at TCT 2013.
Neil E. Moat, MB, BS, MS, FRCS, of Royal Brompton Hospital in London, presented updated data from the Global Valve-in-Valve Registry that showed high rates of 30-day mortality (9.1% vs. 6.6%) and coronary obstruction (5.4% vs. 1.4%) among patients with stentless valves vs. stented valves.
At 1 year, however, patients with stentless valves had only a slightly higher rate of death from any cause than patients with stented valves (17.9% vs. 16.6%; P=.683).
About 20% of patients in the registry had stentless valves. The most common types were homografts (31%), Freestyle (Medtronic; 17%), Biocor (St. Jude; 12%) and Toronto SPV (St. Jude; 11%).
Rates of device malpositioning were higher with stentless valves (16.1%) compared with stented Mosaic (14%) and stented non-Mosaic (9%) valves.
Technical tips
The data show valve-in-valve TAVR is feasible for patients with degenerative stentless bioprosthetic valves, but only with proper preparation, Moat said.
“Detailed pre-procedural planning is absolutely essential,” he noted.
Necessary steps include use of multislice CT to evaluate the aortic root, a determination of the precise location of the coronary ostia, and evaluation of the size and shape of the aortic sinuses.
“For all TAVR, particularly for valve-in-valve for stentless valves, it is absolutely crucial for you to know where your coronary ostia lie,” Moat said. “If you have well-developed aortic sinuses, there is a lot more room to move without impinging on the coronary ostia.”
The type and size of the previous implant also must be verified.
The label size of a homograft typically reflects its inside diameter, whereas the label size of stentless bioprostheses are determined by outside diameter, Moat said. He noted the Freestyle root valve is labeled 27 mm, but its functional diameter is 23 mm.
“That is going to make a big difference,” Moat said. “Label size is not the effective orifice size. Absolute attention to detail in sizing is vital to achieving a good outcome.”
Deployment can be made more challenging because degenerated surgical bioprostheses often lack fluoroscopic markers.
“Somewhat paradoxically, the calcification in the homografts often can help you in the commercial stentless bioprostheses,” Moat said.
Transesophageal echocardiography is necessary to facilitate positioning, and a dual pigtail technique may be beneficial.
Moat advised against balloon aortic valvuloplasty prior to TAVR.
“It’s very rarely needed, and it may be deleterious in terms of making regurgitation even more severe,” he said.
Moat suggested rapid pacing for patients with severe regurgitation. He also recommended the pursuit of a “more ventricular implant” to optimize positioning accuracy.
“With CoreValve or a native valve, you’re probably aiming for 2 mm to 4 mm,” Moat said. “Here, I think you probably want to be aiming for 4 mm, or even 6 mm to 8 mm.”
For more information:
Moat N. TAVI valve-in-valve for failing stentless valves: Technical tips and clinical outcomes. Presented at: TCT 2013; Oct. 27-Nov. 1, 2013; San Francisco.
Disclosure: Moat reports receiving consulting fees/honoraria from Medtronic.
