Commentary: A new little piece for a great puzzle.

Valentina Mancini, MD, Aziz Omar, MD, and Michele Di Mauro, MD, PhD, MSc

No route for ViV should be ineludibly foreclosed in high-risk redo cases; in this case report, the authors had success with a transapical approach.

See Article page 118 in the December 2020 issue.

Recent decades have seen an increasing number of aortic valve replacements (AVRs) performed each year, with a significant shift from mechanical prosthesis to bioprosthesis implantation owing to the reluctance of even younger patients to take oral anticoagulants. Both European and American guidelines have supported bioprosthesis implantation in patients age >60 years. However, with the average lifespan of a bioptosthesis, estimated at 15 years in elderly patients but less in younger patients, we should expect a significant increase in patients with structural degeneration and failure of aortic valve bioprostheses.1, 2, 3

Redo surgical operation carries a high risk, especially in patients with a patent previous coronary bypass associated with a degenerated AVR and serious comorbidities. Transcatheter aortic valve-in-valve (ViV) implantation in a failed bioprosthesis appears to be an increasingly good option with extensive worldwide experience.

Moreover, with the advent of transcatheter aortic valve replacement (TAVR), the number of patients needing a further AVR is expected to increase; thus, it makes sense to evaluate the transcatheter ViV approach for a degenerated TAVR, as in the case reported by Ricciardi and colleagues. After careful evaluation with the heart team, the authors chose the transapical route for TAVR.

Recently published long-term results of the VIVID Registry reported a rate of reintervention for TAVR degeneration at 8 years of 93.5%; 16 of 40 patients (40%) needing a redo received a new TAVR. The Edwards balloon-expandable valve, as used in this case, was associated with a high risk of new intervention (hazard ratio [HR], 3.34; P = .02). Interestingly, among 1006 patients undergoing aortic VIV, a transapical route was used in roughly 25%, although non-transfemoral access was identified as an independent risk factor (HR, 1.43) for lower survival. However, as noted by the authors, little is known about the results of transapical ViV for TAVR degeneration, and this interesting case report adds a new piece to the great puzzle of ViV.