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Valve in Valve

2012; Lippincott Williams & Wilkins; Volume: 126; Issue: 19 Linguagem: Holandês

10.1161/circulationaha.112.133777

1524-4539

E. Murat Tuzcu, Samir Kapadia, Lars G. Svensson,

Mechanical Failure Analysis and Simulation

HomeCirculationVol. 126, No. 19Valve in Valve Free AccessEditorialPDF/EPUBAboutView PDFView EPUBSections ToolsAdd to favoritesDownload citationsTrack citationsPermissions ShareShare onFacebookTwitterLinked InMendeleyReddit Jump toFree AccessEditorialPDF/EPUBValve in ValveAnother Milestone for Transcatheter Valve Therapy E. Murat Tuzcu, MD, Samir R. Kapadia, MD and Lars G. Svensson, MD, PhD E. Murat TuzcuE. Murat Tuzcu From the Departments of Cardiovascular Medicine (E.M.T., S.R.K.) and Cardiothoracic Surgery (L.G.S.), Cleveland Clinic, Cleveland, OH. , Samir R. KapadiaSamir R. Kapadia From the Departments of Cardiovascular Medicine (E.M.T., S.R.K.) and Cardiothoracic Surgery (L.G.S.), Cleveland Clinic, Cleveland, OH. and Lars G. SvenssonLars G. Svensson From the Departments of Cardiovascular Medicine (E.M.T., S.R.K.) and Cardiothoracic Surgery (L.G.S.), Cleveland Clinic, Cleveland, OH. Originally published10 Oct 2012https://doi.org/10.1161/CIRCULATIONAHA.112.133777Circulation. 2012;126:2280–2282Other version(s) of this articleYou are viewing the most recent version of this article. Previous versions: January 1, 2012: Previous Version 1 The first mechanical heart valve prosthesis, designed by Dr Charles Hufnagel, was implanted to the descending aorta of a 30-year-old woman with severe aortic regurgitation in 1952.1 Eight years after the initial successful prosthetic valve implantation, Dr Harken sutured a prosthetic valve (Starr Edwards Valve) to the aortic annulus after removing the diseased native valve. During the ensuing years, different types of valves made from pyrolytic carbon were tried. Though they successfully remedied the aortic valve disease, mechanical prosthesis required lifelong anticoagulation, resulting in high rates of bleeding and thrombosis complications.Article see p 2335In the 1960s, valves with leaflets that were made from animal tissue were developed as an alternative without an anticoagulation requirement. Indeed, they were superior to mechanical prosthesis in that regard, but they did not last nearly as long. In randomized trials of bioprosthetic or mechanical valves, which started enrollment in 1970s, primary valve failure and reoperation rates were higher in patients receiving bioprosthetic valves, especially in patients aged 20 mm Hg after TAVR. In patients with small surgical prosthesis (internal diameter 75% of the bioprosthesis were <23 mm. There is a large variation in internal diameter of bioprosthetic valves, ranging from 17 mm to 20 mm for a 21-mm and 15 mm to 19 mm for a 19-mm valve, based on intraoperative measurements. The measurements not only depend on the valve type, but also on whether the bioprosthetic valve is placed surpra- or intra-annularly and whether valve pledgets are placed above or below the annulus. Understanding the complexity of the dimensions and knowing the true internal diameter of the prosthetic valve are critical in the planning of VIV procedure.The opening that will accommodate the new prosthesis is also determined, albeit to a lesser extent, by presence and severity of pannus formation, bulky nature of the degenerated and calcified prosthetic valve leaflets, and the severity of stenosis. The issue of internal diameter size of the diseased valve is more important for the Edwards Sapien valve because of its intra-annular positioning, than for the CoreValve which has functioning leaflets above the minimum internal diameter.Creating a relatively small effective orifice area and consequently high transvalvular gradients will frequently lead to patient–prosthesis mismatch. Whether this less than optimal orifice translates into higher long-term mortality or functional impairment remains to be seen. Available data in the surgical literature suggest that there may be a price to pay for larger residual gradients. With that said, for patients with no surgical option as a result of multiple comorbidities, expectations may be different. For the time being, VIV for a no-option patient with severely dysfunctional 19-mm or 21-mm prosthesis may not be a perfect solution, but it may offer an acceptable result with improvement in symptoms, particularly with a supra-annular valve.15Coronary OcclusionThe data in the registry highlight another critical procedural problem and point to the importance of careful patient selection and procedure planning. Coronary artery occlusion with attendant 57% mortality occurred more frequently in the stentless valves and valves with leaflet mounted on the outside of the frames (Figure). It is not clear whether or not there is an interaction between the diseased prosthesis and the type of TAVR used, although there was no difference in the frequency of the coronary occlusion between the 2 types of transcatheter valve. To prevent this frequently lethal complication, we need to examine the relationships between the coronary artery ostia, the bioprosthetic valve sewing ring, the leaflets, the sinotubular junction, and Sinuses of Valsalva. For the time being we should either avoid or use extreme caution in using the VIV technique in the particular prosthesis mentioned above that leaves little space between the prosthetic leaflets and coronary ostia.Download figureDownload PowerPointFigure. A, Stented bioprosthesis with leaflets mounted inside the frame struts. B, Stentless valve is sewn to the aortic wall with coronary ostia above open to the stentless valve rim aorta with reduction in aortic root dimensions (subcoronary insertion). C, Stentless valve root replacement with mobilized coronary ostia sewn to the stentless valve root with consequent reduction in the aortic root and coronary sinuses (root replacement). D through H, Stented valve with leaflets mounted outside of the frame struts. Valve in valve is shown in the bottom panels for respective valves. Calcific deposits on the valve (blue arrows) and prosthetic valve annulus pannus formation (yellow arrows) on the valve could potentially affect the expansion of the transcatheter valve. It is also possible that limited space in the aortic root in stentless valves and in valves with leaflets mounted outside could potentially compromise flow to the coronary arteries.Malpositioned ValveThe malpositioning rate of 15.3% and the need for a second TAVR valve in 8.4% of patients are surprisingly high. The valve that moves cranially during deployment up the aorta can often be managed via catheter techniques, but if it moves in toward the left ventricle open-heart surgery may be necessary. These complications can potentially be prevented by clear understanding of the anatomy of different valves, preprocedural planning with CT scan, and use of guiding intraprocedural radioscopic software for positioning.13Long-Term OutcomeThere appears to be no loss of improved valve function in a small number of patients who had 1-year echocardiograms. Follow-up is too short and very limited to draw comfort for durability of the VIV technique. The longer term follow-up from larger TAVR cohorts cannot be readily used for VIV procedures. For the time being, the impact of the frequently constrained conditions of the functioning VIV, interaction between 2 different prosthetic surfaces on the durability of the transcatheter valve, is not clear.Bioprosthesis Now, TAVR Later?The question at hand is as follows: does TAVR offer a reasonable solution to the difficult problem of the severely symptomatic patient with malfunctioning aortic prosthesis who is not a surgical candidate or at very high risk for surgical mortality and morbidity? The answer is a qualified yes; not all surgical prostheses are suitable, and much improvement in technology and procedural technique is needed.The question for the future is as follows: Should we take the option of VIV-TAVR technique into consideration when deciding the surgical valve type for aortic valve disease patients of all ages? The answer is a cautious maybe. In the future, availability of new versions of TAVR devices specifically for VIV will make this approach more feasible as long as the durability issue is addressed. But the size of the surgically implanted valve will continue to be the most important determinant of the success of the VIV procedure. Accordingly, surgeons who envision a prospective TAVR procedure if a valve bioprosthesis fails should make sure a large valve is implanted during the first surgery.16 This may require wider use of the root enlargement procedures.17Valve in valve is another milestone in the advance of transcatheter valve therapies. Dvir et al should be congratulated for reporting the initial global experience. They show us the promise and the pitfalls of the new technique and point to the hard work ahead to overcome the challenges.DisclosuresDr Tuzcu is an unpaid member of the executive committee and investigator of the Placement of Aortic Transcatheter Valve (PARTNER) trial. Dr Kapadia is an unpaid member of the steering committee and investigator of the PARTNER trial. Dr Svensson is an unpaid member of the executive committee and investigator of the PARTNER trial. The other authors report no conflicts.FootnotesThe opinions expressed in this article are not necessarily those of the editors or of the American Heart Association.Correspondence to E. Murat Tuzcu, MD, Department of Cardiovascular Medicine, J-2-3, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH 44124. E-mail [email protected]orgReferences1. Hufnagel CA, Harvey WP. The surgical correction of aortic regurgitation preliminary report. Bull Georgetown Univ Med Cent. 1953; 6:60–61.MedlineGoogle Scholar2. Oxenham H, Bloomfield P, Wheatley DJ, Lee RJ, Cunningham J, Prescott RJ, Miller HC. Twenty year comparison of a Bjork-Shiley mechanical heart valve with porcine bioprostheses. Heart. 2003; 89:715–721.CrossrefMedlineGoogle Scholar3. 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Pascual I, Avanzas P, Hernández-Vaquero D, Díaz R, del Valle R, Padrón R, Lorca R, León V, Martín M, Alfonso F and Morís C (2019) Self-expanding transcatheter aortic valve implantation for degenerated Mitroflow bioprosthesis: Early outcomes, International Journal of Cardiology, 10.1016/j.ijcard.2019.01.094, 287, (53-58), Online publication date: 1-Jul-2019. Alnasser S, Cheema A, Simonato M, Barbanti M, Edwards J, Kornowski R, Horlick E, Wijeysundera H, Testa L, Bedogni F, Amrane H, Walther T, Pelletier M, Latib A, Laborde J, Hildick-Smith D, Kim W, Tchetche D, Agrifoglio M, Sinning J, van Boven A, Kefer J, Frerker C, van Mieghem N, Linke A, Worthley S, Asgar A, Sgroi C, Aziz M, Danenberg H, Labinaz M, Manoharan G, Cheung A, Webb J and Dvir D (2017) Matched Comparison of Self-Expanding Transcatheter Heart Valves for the Treatment of Failed Aortic Surgical Bioprosthesis, Circulation: Cardiovascular Interventions, 10:4, Online publication date: 1-Apr-2017. Dasi L, Hatoum H, Kheradvar A, Zareian R, Alavi S, Sun W, Martin C, Pham T, Wang Q, Midha P, Raghav V and Yoganathan A (2016) On the Mechanics of Transcatheter Aortic Valve Replacement, Annals of Biomedical Engineering, 10.1007/s10439-016-1759-3, 45:2, (310-331), Online publication date: 1-Feb-2017. Svensson L, Pillai S, Rajeswaran J, Desai M, Griffin B, Grimm R, Hammer D, Thamilarasan M, Roselli E, Pettersson G, Gillinov A, Navia J, Smedira N, Sabik J, Lytle B and Blackstone E (2016) Long-term survival, valve durability, and reoperation for 4 aortic root procedures combined with ascending aorta replacement, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2015.10.113, 151:3, (764-774.e4), Online publication date: 1-Mar-2016. Aguirre J, Waskowski R, Poddar K, Kapadia S, Krishnaswamy A, McCullough R, Mick S, Navia J, Roselli E, Tuzcu M, Sabik J, Lytle B and Svensson L (2014) Transcatheter aortic valve replacement: Experience with the transapical approach, alternate access sites, and concomitant cardiac repairs, The Journal of Thoracic and Cardiovascular Surgery, 10.1016/j.jtcvs.2014.05.019, 148:4, (1417-1422), Online publication date: 1-Oct-2014. Olmos C, Marcos-Alberca P, Islas F, Viliani D, Almería C, Rodríguez E, Macaya C and Pérez de Isla L (2013) Malfunctioning Mitral Valve-in-Valve Bioprosthesis Assessment by 3-Dimensional Transesophageal Echocardiography, Circulation, 128:10, (e139-e140), Online publication date: 3-Sep-2013. Desai C, Roselli E, Svensson L and Bonow R (2013) Transcatheter Aortic Valve Replacement: Current Status and Future Directions, Seminars in Thoracic and Cardiovascular Surgery, 10.1053/j.semtcvs.2013.09.002, 25:3, (193-196), Online publication date: 1-Sep-2013. November 6, 2012Vol 126, Issue 19 Advertisement Article InformationMetrics © 2012 American Heart Association, Inc.https://doi.org/10.1161/CIRCULATIONAHA.112.133777PMID: 23052029 Originally publishedOctober 10, 2012 Keywordsaortic valve stenosistranscatheter valvesEditorialsPDF download Advertisement SubjectsCardiovascular Surgery