Percutaneous Valve-in-Valve implantation for the Treatment of Aortic, Mitral and Tricuspid Structural Bioprosthetic Valve Degeneration

Background: Structural bioprosthetic valve deterioration is frequently found in clinical practice and its incidence is expected to increase with the aging of the population. The percutaneous Valve-in-Valve approach (VIV) is an established alternative for patients found at increased surgical risk by the local heart team. We aim to report our 8 years experience in the treatment of patients with aortic, mitral and tricuspid bioprosthetic valve deterioration using the VIV technique.

Methods: Outcomes of 89 consecutive patients treated for symptomatic bioprosthetic valve deterioration using VIV at our institution were analyzed and reported according to the Valve Academic Research Consortium 2 definitions.

Results: Follow-up time continued up to 7.8 years, mean 1,065 ± 789 days. The VIV procedure was performed in the aortic position in 51 (57%) patients, mean age 80 ± 9.7 years, 25 (50%) females, mean STS score: 7.3 ± 5.3; in the mitral position: 30 (34%) patients (13 trans-septal), mean age 76 ± 9.7 years, 21 (70%) females, mean STS score: 9.5 ± 5.8 and in the tricuspid position in 8 (9%) female patients with mean STS scores of 4.5. The aortic-VIV procedures were performed via the trans-femoral, trans-apical and trans-axillary routes in 44 (87%), 2 (4%) and 5 (10%) cases; respectively, with the use of a self-expandable and balloon-expandable devices in 45 and 3 cases; respectively. Pre-procedural NYHA functional-class was III/IV in most patients (72%), enhanced to I/II in the majority (77%) at 1-month and preserved stable in long term follow-up. Mitral-VIV procedures were performed via the trans-apical route in all patients till the end of 2016 (16 cases) and by trans-venues-trans-septal since the beginning of 2017 (14 cases). The composite end-point of device success was achieved in all patients. Eight VIV implantations in a failed tricuspid bioprosthetic valve were also successfully performed. Survival rates for all VIV patients was 97.6% at 30 days and 88% at 1-year (e.g. 92% aortic and 76% mitral position). Most deaths were due to non cardiovascular cause.

Conclusions: This report on one of the worlds’ largest single center VIV-cohort demonstrates that using the VIV technique to treat a wide range of valve failure modes and in different positions is feasible, safe and very effective.