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OBJECTIVE:
A major limitation of valve-in-valve (ViV) implantations is transcatheter heart valve (THV) underexpansion, which is associated with elevated post procedural gradients. Supra-annular THV device positioning may be advantageous in achieving lower gradients following ViV. Our objective was to utilize large clinical data and in-vitro bench testings in order to examine whether higher THV implantation would be associated with improved hemodynamics and to define optimal depth targets that would allow for ideal hemodynamics after ViV using different THV devices.
METHODS:
In-vitro bench testing using pulse duplicators with three different THV devices were performed, having up to 13 different depths of implantation for each THV (CoreValve Evolut, CVE, Medtronic; SAPIEN XT, SXT, Edwards Lifesciences; Portico, St. Jude Medical). In addition, clinical cases from the Valve-in-Valve International Data (VIVID) registry were analyzed. Images underwent blinded corelab analysis for the establishment of optimal implantation depth.
RESULTS:
In-vitro analysis for the CVE, SXT and Portico suggested as well that higher implantation is associated with lower gradients. A total of 289 patients (159 CVE and 130 SXT) were included in the analysis. High implantation had significantly smaller incidence of elevated gradients when compared to deep implantation (CVE: 15% vs. 34.5%, p=0.03, SXT: 20.8% vs. 44.3%, p=0.04). Optimal implantation depth were defined: CVE, 0 to 5mm depth; SXT, 0 to 10% frame height (0 to 2mm); Portico, 0 to 2mm.
CONCLUSIONS:
Optimal implantation of THV devices in the context of ViV involes higher positioning. Specific targets for positioning can be offered for each major THV device.