TAVR for failing surgical valves: Lessons learned from new 5-year data

VIV results at five years

The registry enrolled 100 low- and intermediate-risk patients who had previously undergone aortic valve replacement and were experiencing a failure of their bioprosthetic valves. These patients underwent transfemoral TAVR using the Edwards Lifesciences Sapien 3 valve. Notably, current U.S. guidelines approve aortic valve-in-valve procedures only for high-risk patients, making this study particularly relevant for expanding treatment options in lower-risk groups.

Malaisrie emphasized that these results support the viability of aortic valve-in-valve procedures for patients with failing bioprosthetic valves who are still considered low-risk. With an average patient age of 67 at the time of TAVR, many had likely undergone their initial valve replacement in their 50s, raising important considerations for lifetime management strategies.

Implications for lifetime valve treatment pathways

The discussion of lifetime management has gained momentum, particularly as younger patients increasingly receive bioprosthetic valves. While TAVR is often preferred for its minimally invasive nature, there are concerns about the long-term feasibility of repeated TAVR procedures due to anatomical constraints.

Malaisrie noted that the findings support an initial surgical aortic valve replacement (SAVR) strategy in younger patients, followed by TAVR as a second intervention. This approach helps preserve treatment options for future interventions should the valve fail again.

Durability and hemodynamics of VIV

The study also provided insights into valve performance over time. At five years, mean pressure gradients remained at 17-19 mmHg, which, while acceptable, were slightly higher than gradients observed in native aortic stenosis TAVR procedures. This highlights the need for procedural optimization to improve hemodynamics in valve-in-valve cases.

One key strategy to enhance outcomes is optimizing the initial aortic valve replacement. Surgeons could perform root enlargements to accommodate larger prosthetic valves, ultimately allowing for better long-term valve-in-valve performance with lower gradients. Additionally, proper sizing and positioning of the transcatheter valve within the surgical valve are critical to avoiding complications such as leaflet pinwheeling and malalignment.

He said creating a larger annulus in patients during surgery would help future valve-in-valve procedures to allow for a larger orifice area that can accommodate a second, or even a third valve-in-valve, down the road.