Late Failing Transcatheter Aortic Valve Implantation (TAVI) Prosthesis in 25 Patients: Single-Center Experience of Valve-in-valve and Surgical Redo Procedures

Objectives: Experience of late failing TAVI prostheses is less so far. Information about postinterventional outcome of redo procedures in these cases is sparse.

Methods: All patients' data treated with a late failing TAVI prosthesis were collected into our institutional TAVIK-registry. Patient characteristics, perioperative data, post-interventional complications in accordance to Valve Academic Research Consortium-2, and 30day, 12month and follow-up mortality were analyzed of all patients who underwent a redo intervention.

Results: In total, 25 patients were treated with late failing TAVI prosthesis; these were 6 CoreValve prosthesis (sizes 26 mm, n = 1; 29 mm, n = 3; 31 mm, n = 1; unknown size, n = 1) and 19 Sapien prosthesis (Sapien, n = 5; XT, n = 11; S3, n = 3). At the time of redo procedure: mean age was 83.4 ± 4.9 years (range 75–94); logistic EuroSCORE I was 36.8 ± 16.7%. Follow-up was achieved at 17.6 months (range 1–73). Time between primary TAVI and redo procedure was 43.9 ± 32.5 months (range 1.5–91.1). Main mode of prosthetic failure was stenosis in 14 (56.0%) patients, regurgitation in 10 (40.0% - including valve insufficiency in 2, and paravalvular leakage (PVL) in 8) and endocarditis in 1 (4.3%). One endocarditis was observed 24months after Sapien S3 TAVI; this valve was surgically changed. 4 of 6 CoreValve patients (66.7%) experienced severe PVL. Valve-in-valve (VinV) TAVI procedures were provided in 20 cases (80.0%; 4 transapical and 16 transfemoral) with 14 balloon-expandable and 6 self-expandable prostheses. Main mode of prosthetic failure in 8 of 9 small Sapien valves (23 mm) was stenosis within 62.0 ± 18.3 months. Procedural success rate was 92.0%. In the VinV group, one myocardial infarction due to acute coronary obstruction occurred and made surgical conversion necessary. In 5 TAVI-patients (20.0%; 4 Sapien, 1 CoreValve) a surgical aortic valve replacement as redo procedure was performed. 30day, 12month and follow-up mortality was 0, 8.7, and 17.4%. One major stroke occurred in the VinV group within 30days. In one VinV patient, a mean gradient >20mmHg was observed (Evolut R 26 mm in XT 23 mm).

Conclusion: Late prosthetic failure in these 25 TAVI treated patients occurred in the average at 44 months. Redo procedures in late failing TAVI prosthesis, either VinV-TAVI or even conventional surgery, could be safely performed with good results. In VinV-TAVI procedures with low coronary distance to the annulus acute coronary obstruction may be fatal.