Thorac Cardiovasc Surg 2017; 65(03): 218-224
DOI: 10.1055/s-0036-1584356
Original Cardiovascular
Georg Thieme Verlag KG Stuttgart · New York

Does Undersizing of Transcatheter Aortic Valve Bioprostheses during Valve-in-Valve Implantation Avoid Coronary Obstruction? An In Vitro Study

Sina Stock
1   Department of Cardiac and Thoracic Vascular Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Schleswig-Holstein, Germany
,
Michael Scharfschwerdt
1   Department of Cardiac and Thoracic Vascular Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Schleswig-Holstein, Germany
,
Roza Meyer-Saraei
2   Department of Cardiology, Angiology and Intensive Care Medicine, Universitätsklinikum Schleswig-Holstein, Lübeck, Schleswig-Holstein, Germany
,
Doreen Richardt
1   Department of Cardiac and Thoracic Vascular Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Schleswig-Holstein, Germany
,
Efstratios I. Charitos
3   Department of Cardiac and Thoracic Surgery, Universitätsklinikum Halle, Halle, Sachsen-Anhalt, Germany
,
Hans-Hinrich Sievers
1   Department of Cardiac and Thoracic Vascular Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Schleswig-Holstein, Germany
,
Thorsten Hanke
1   Department of Cardiac and Thoracic Vascular Surgery, Universitätsklinikum Schleswig-Holstein, Lübeck, Schleswig-Holstein, Germany
› Author Affiliations
Further Information

Publication History

20 February 2016

03 May 2016

Publication Date:
15 June 2016 (online)

Abstract

Background The transcatheter aortic valve-in-valve implantation (TAViVI) is an evolving treatment strategy for degenerated surgical aortic valve bioprostheses (SAVBs) in patients with high operative risk. Although hemodynamics is excellent, there is some concern regarding coronary obstruction, especially in SAVB with externally mounted leaflet tissue, such as the Trifecta (St. Jude Medical Inc., St. Paul, Minnesota, United States). We investigated coronary flow and hydrodynamics before and after TAViVI in a SAVB with externally mounted leaflet tissue (St. Jude Medical, Trifecta) with an undersized transcatheter aortic valve bioprosthesis (Edwards Sapien XT; Edwards Lifesciences LLC, Irvine, California, United States) in an in vitro study.

Materials and Methods An aortic root model was constructed incorporating geometric dimensions known as risk factors for coronary obstruction. Investigating the validity of this model, we primarily performed recommended TAViVI with the Sapien XT (size 26 mm) in a Trifecta (size 25 mm) in a mock circulation. Thereafter, hydrodynamic performance and coronary flow (left/right coronary diastolic flow [lCF/rCF]) after TAViVI with an undersized Sapien XT (size 23 mm) in a Trifecta (size 25 mm) were investigated at two different coronary ostia heights (COHs, 8 and 10 mm).

Results Validation of the model led to significant coronary obstruction (p < 0.001). Undersized TAViVI showed no significant reduction with respect to coronary flow (lCF: COH 8 mm, 0.90–0.87 mL/stroke; COH 10 mm, 0.89–0.82 mL/stroke and rCF: COH 8 mm, 0.64–0.60 mL/stroke; COH 10 mm, 0.62–0.58 mL/stroke). Mean transvalvular gradients (4–5 mm Hg, p < 0.001) increased significantly after TAViVI.

Conclusions In our in vitro model, undersized TAViVI with the balloon-expandable Sapien XT into a modern generation SAVB (Trifecta) successfully avoided coronary flow obstruction.

 
  • References

  • 1 Gurvitch R, Cheung A, Bedogni F, Webb JG. Coronary obstruction following transcatheter aortic valve-in-valve implantation for failed surgical bioprostheses. Catheter Cardiovasc Interv 2011; 77 (3) 439-444
  • 2 Dvir D, Webb J, Brecker S , et al. Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in-valve registry. Circulation 2012; 126 (19) 2335-2344
  • 3 Dvir D, Assali A, Vaknin-Assa H , et al. Transcatheter aortic and mitral valve implantations for failed bioprosthetic heart valves. J Invasive Cardiol 2011; 23 (9) 377-381
  • 4 Gurvitch R, Cheung A, Ye J , et al. Transcatheter valve-in-valve implantation for failed surgical bioprosthetic valves. J Am Coll Cardiol 2011; 58 (21) 2196-2209
  • 5 Ye J, Webb JG, Cheung A , et al. Transapical transcatheter aortic valve-in-valve implantation: clinical and hemodynamic outcomes beyond 2 years. J Thorac Cardiovasc Surg 2013; 145 (6) 1554-1562
  • 6 Barge-Caballero G, Salgado-Fernández J, Vázquez-González N. Acute coronary artery occlusions complicating a valve-in-valve-in-valve procedure. Heart 2013; 99 (8) 591-592
  • 7 Azadani AN, Jaussaud N, Matthews PB , et al. Aortic valve-in-valve implantation: impact of transcatheter- bioprosthesis size mismatch. J Heart Valve Dis 2009; 18 (4) 367-373
  • 8 Azadani AN, Jaussaud N, Matthews PB, Ge L, Chuter TA, Tseng EE. Transcatheter aortic valves inadequately relieve stenosis in small degenerated bioprostheses. Interact Cardiovasc Thorac Surg 2010; 11 (1) 70-77
  • 9 Bapat VN, Attia R, Thomas M. Effect of valve design on the stent internal diameter of a bioprosthetic valve: a concept of true internal diameter and its implications for the valve-in-valve procedure. JACC Cardiovasc Interv 2014; 7 (2) 115-127
  • 10 Ribeiro H, Webb J, Makkar R , et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. J Am Coll Cardiol 2013; 62 (17) 1552-1562
  • 11 Scharfschwerdt M, Misfeld M, Sievers HH. The influence of a nonlinear resistance element upon in vitro aortic pressure tracings and aortic valve motions. ASAIO J 2004; 50 (5) 498-502
  • 12 Transonic Systems Inc. Flow-based Intraoperative Coronary Graft Patency Assessment. Ithaca, New York, USA: Transonic Systems Inc; 2002: 7-11
  • 13 Bapat VN, Attia RQ, Condemi F , et al. Fluoroscopic guide to an ideal implant position for Sapien XT and CoreValve during a valve-in-valve procedure. JACC Cardiovasc Interv 2013; 6 (11) 1186-1194
  • 14 Russ C, Hopf R, Hirsch S , et al. Simulation of transcatheter aortic valve implantation under consideration of leaflet calcification. Conf Proc IEEE Eng Med Biol Soc 2013; 2013: 711-714
  • 15 Webb JG, Dvir D. Transcatheter aortic valve replacement for bioprosthetic aortic valve failure: the valve-in-valve procedure. Circulation 2013; 127 (25) 2542-2550
  • 16 Bapat V, Mydin I, Chadalavada S, Tehrani H, Attia R, Thomas M. A guide to fluoroscopic identification and design of bioprosthetic valves: a reference for valve-in-valve procedure. Catheter Cardiovasc Interv 2013; 81 (5) 853-861
  • 17 Haussig S, Schuler G, Linke A. Treatment of a failing St. Jude Medical Trifecta by Medtronic Corevalve Evolut valve-in-valve implantation. JACC Cardiovasc Interv 2014; 7 (7) e81-e82
  • 18 Chakravarty T, Jilaihawi H, Nakamura M , et al. Pre-emptive positioning of a coronary stent in the left anterior descending artery for left main protection: a prerequisite for transcatheter aortic valve-in-valve implantation for failing stentless bioprostheses?. Catheter Cardiovasc Interv 2013; 82 (4) E630-E636
  • 19 Urena M, Nombela-Franco L, Doyle D , et al. Transcatheter aortic valve implantation for the treatment of surgical valve dysfunction (“valve-in-valve”): assessing the risk of coronary obstruction. J Card Surg 2012; 27 (6) 682-685
  • 20 Khawaja MZ, Haworth P, Ghuran A , et al. Transcatheter aortic valve implantation for stenosed and regurgitant aortic valve bioprostheses CoreValve for failed bioprosthetic aortic valve replacements. J Am Coll Cardiol 2010; 55 (2) 97-101
  • 21 Seiffert M, Franzen O, Conradi L , et al. Series of transcatheter valve-in-valve implantations in high-risk patients with degenerated bioprostheses in aortic and mitral position. Catheter Cardiovasc Interv 2010; 76 (4) 608-615
  • 22 Gotzmann M, Korten M, Bojara W , et al. Long-term outcome of patients with moderate and severe prosthetic aortic valve regurgitation after transcatheter aortic valve implantation. Am J Cardiol 2012; 110 (10) 1500-1506
  • 23 Tamburino C, Capodanno D, Ramondo A , et al. Incidence and predictors of early and late mortality after transcatheter aortic valve implantation in 663 patients with severe aortic stenosis. Circulation 2011; 123 (3) 299-308
  • 24 Vasa-Nicotera M, Sinning JM, Chin D , et al. Impact of paravalvular leakage on outcome in patients after transcatheter aortic valve implantation. JACC Cardiovasc Interv 2012; 5 (8) 858-865
  • 25 Babin-Ebell J, Freiherr Grote H, Sievers HH, Scharfschwerdt M. Impact of graft size and commissural resuspension height on aortic valve competence in valve-sparing aortic replacement under physiological pressures. Thorac Cardiovasc Surg 2009; 57 (7) 399-402
  • 26 Berdajs D, Lajos P, Turina M. The anatomy of the aortic root. Cardiovasc Surg 2002; 10 (4) 320-327