The Heart Valve Society

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Stentless vs. Stented Aortic Valve-in-Valve Implantation: Insights from the Valve-in-Valve International Data Registry (VIVID)
Alison Duncan1, Neil Moat1, Matheus Simonato2, John Webb3, Vinayak Bapat4, Thierry Lefevre5, Guilherme Attizzani6, Jose Maria Hernandez7, Pedro Lemos8, Robert Welsh9, Alessandro Iadanza10, Stefano Salizzoni11, Marco Agrifoglio12, Patrizia Presbitero13, Giuseppe Bruschi14, Filip Casselman15, Dominique Himbert16, Raj Makkar17, Arash Salemi18, Farrel Hellig19, Sameer Gafoor20, Tarun Chakravarty17, Amit Segev21, Ariel Finkelstein22, Ran Kornowski23, Danny Dvir24.
1Royal Brompton Hospital, London, United Kingdom, 2Escola Paulista de Medicina - UNIFESP, Sao Paulo, Brazil, 3St. Paul's Hospital, Vancouver, BC, Canada, 4Guys and St. Thomas Hospital, London, United Kingdom, 5Institut Cardiovasculaire Paris Sud Massy, Paris, France, 6University Hospitals, Cleveland, OH, USA, 7Hospital Universitario Virgen de la Victoria, Malaga, Spain, 8Faculdade de Medicina da USP, Sao Paulo, Brazil, 9Mazankowski Alberta Heart Institute, Edmonton, AB, Canada, 10Azienda Ospedaliera Universitaria Senese, Siena, Italy, 11Città della Salute e della Scienza, Torino, Italy, 12Cardiologico Monzino, Milan, Italy, 13Humanitas, Milan, Italy, 14Niguarda Hospital, Milan, Italy, 15OLV Clinic, Aalst, Belgium, 16Hôpitaux de Paris, Paris, France, 17Cedars Sinai, Los Angeles, CA, USA, 18Cornell University, New York, NY, USA, 19Sunninghill Hospital, Johannesburg, South Africa, 20Swedish Medical Center, Seattle, WA, USA, 21Sheba Medical Center, Ramat Gan, Israel, 22Tel-Aviv Medical Center, Tel-Aviv, Israel, 23Rabin Medical Center, Petah Tikva, Israel, 24University of Washington Medical Center, Seattle, WA, USA.

OBJECTIVE: Valve-in-valve (ViV) transcatheter aortic implantation (TAVI) is an alternative to redo open heart surgery for patients with a failing aortic bioprosthesis. Unlike degenerate stented aortic bioprostheses, failing stentless bioprostheses lack anatomic markers which may complicate ViV-TAVI. We compared clinical outcomes after ViV-TAVI for failing stentless versus failing stented bioprostheses using the large global registry.
METHODS: 1598 aortic ViV procedures from the ViV International Data (VIVID) registry were investigated (1307 stented bioprostheses, 291 stentless).
RESULTS: Stentless patients were younger (74±13 vs. 78±8years), otherwise there was no difference in gender, severity of NYHA Class, diabetes, peripheral vascular disease, renal disease, previous stroke, chronic lung disease, logistic EuroSCORE (13.6±9.0 vs, 14.7±8.5) or STS mortality risk score (9.0±7.9 vs. 9.4±8.2) between stentless and stented groups. Bioprosthetic failure was due to aortic regurgitation in 57.7% of stentless and 21.1% of stented devices (p<0.001). Baseline effective orifice area was larger (1.31±0.7 vs. 0.93±0.63cm2), and mean gradient was lower (25±18 vs. 38±17mmHg, both p<0.001) in stentless versus stented valves.
Transfemoral access was similar in stentless vs. stented ViV-TAVI (72% vs. 74%), but self-expandable devices was more frequent in stentless bioprostheses (66.8% vs. 54.5%, p<0.001). Initial device malposition was more common in stentless valves (10.6% vs. 6.1%, p=0.008), as was the requirement for a second transcatheter device (7.9% vs. 3.4%) and incidence of coronary obstruction (6.0% vs. 1.5%, both p<0.001). However, post-procedure final aortic valve area was greater (1.74±0.6 vs. 1.42±0.4cm2) and mean gradient was lower (12±7 vs. 19±10mmHg, both p<0.001) in stentless devices. Duration of hospital stay was longer in stentless group (10.8±13.2 vs. 9.3±7.7days, p=0.013), but there was no difference in 30-day (6.6% vs 4.4%, p=0.121) or 1 year mortality (14% stentless vs. 16.6% stented, p = 0.59).
CONCLUSIONS: ViV TAVI for degenerate stentless bioprosthesis is challenging and associated with more device malposition, requirement for second ViV device, and coronary obstruction. However, stentless ViV procedures offers improved device haemodynamics on echocardiography with similar survival rates at 30-days and 1-year.


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