Valve-in-Valve

Transcatheter Aortic Valve Implantation

Michael A. Borger, MD PhD

AATS Postgraduate Symposium

Minneapolis, MN

May 4, 2013

Disclosure

Speaking honoraria:

- Edwards Lifesciences

- St. Jude Medical

- Medtronic

Various Applications of ´Valve-in-valve´

TAVI in SAVR

TAVI in TAVI (bailout)

^ TVI in surgical MVR, PVR, TVR

Case Report

84 y.o. male with NYHA II – III:

- post-AVR 2008 (SJM Trifecta 23 mm)

- moderate AS, mod-to-severe AI

- diffuse atherosclerotic CAD

- pacemaker (DDD)

- COPD (FEV1 1.2L), former smoker

- obesity (BMI 38)

- Parkinson syndrome

- knee replacement 2010

- DVT post-knee replacement

Biological AVR (SJM Trifecta 23mm) with:

- leaflet thickening

- P max/mean 56/38mmHg

- EOA1.0 cm² (planimetry 1.1 cm²)

- mod-to-severe transvalvular AI

Case Report

Case Report

84 y.o. male with NYHA II – III:

- post-AVR 2008 (SJM Trifecta 23 mm)

- moderate AS, mod-to-severe AI

- diffuse atherosclerotic CAD

- pacemaker (DDD)

- COPD (FEV 1.4L), former smoker

- obesity (BMI 38)

- Parkinson syndrome

- knee replacement 2010

- DVT post-knee replacement

Options:

(1) Redo AVR

(2) Redo Bentall

(3) Medical management

(4) TAVR

Three Months Postop

• Good position and function of CoreValve:

– P max/mean 16/8 mm Hg,

– EOA 1.4 cm² (VTI 2.0 cm², LVOT 19 mm)

– no paravalvular leak, no AI

– EF 61%

• Improvement in symptoms (NYHA I-II)

20 30 40 50 60 70 80 90 years

VinV: from animal to FIM human

• recent trend towards bioprosthesis1

• expected durability 15-20 years2,3

• increasing life expectancy

1. AHA-Guidelines; Circulation 2006 2. Marchand; Ann Thorac Surg 2001

3. Borger; J Heart Valve Dis 2006

=> more elderly patients (comorbidities) with

degenerated bioprosthesis requiring redo procedures in

the future

- increased risk profile -

Structural Valve Degeneration

Pericardial: calcification,

impaired flexibility, stenosis

Porcine: calcification,

leaflet tear, insufficiency

V-in-V: Experimental animal studies

VinV: SAPIEN 23 in Perimount 21

first human transapical VinV 03/2007 in Leipzig (Perimount 21)

VinV: SAPIEN 23 in Perimount 21

first human transapical ViV implantation 2007 at our center

VinV: SAPIEN 26 in Hancock 25

VinV: SAPIEN 23 in Mosaic 21

VinV: SAPIEN 23 in Epic 21

Transapical V-in-V Leipzig experience

transapical V-in-V Leipzig experience

Kempfert et al., ATS 2010

VinV for degenerated aortic bioprosthesis

CE Perimount

mitral 25 mm

Edwards

SAPIEN 23 mm

Valve-in-a-Valve

(VinV)

+

Benchmark testing?

•Which valve in which valve

•Hemodynamic performance

•Measurements

Inner Diameters of Select Bioprostheses

Ferrari E EJCTS 2012;41:485-90

Valve-in-Valve Literature

Aortic V-in-V – Literature

Webb J et al. Circulation 2010

transapical V-in-V Leipzig experience

Residual gradient after

transapical aortic V-in-V (echo)

0

10

20

30

40

50

Leipzig experience

n=11

Vancoucer experience

n=10

maximal gradient

mean gradient

mmHg

Webb J et al. Circulation 2010; Kempfert et al. ARS 2010

Specific considerations

Azadani et al., ICVTS 2010

Technical considerations

Azadani et al., ICVTS 2010

Transfemoral (CoreValve) V-in-V

Transfemoral (CoreValve) V-in-V

Transfemoral (CoreValve) V-in-V

TAVI Valve-in-Valve

TAVI represents a good option for patients

with failing bioprosthetic valves

TAVI V-in-V can be achieved with low rates of

morbidity and mortality

Pre-procedure determination of optimal TAVI

valve size is crucial

TAVI V-in-V may justify lowering recommended

age for bioprosthetic AVR (at least 21 mm!)

Thank you

michael.borger@med.uni-leipzig.de