The International Trifecta^TM and Epic^TM Valve-in-Valve Registry: Insights Into Clinical & Hemodynamic Outcomes

Little is known about the clinical and hemodynamic outcome of valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) for failed Trifecta surgical aortic bioprotheses.

We aimed to compare outcomes of valve-in-valve transcatheter aortic valve replacement (ViV-TAVR into failed Trifecta^TM vs. ViV-TAVR into a standard aortic bioprosthetic valve with internally mounted leaflets (Epic^TM, Abbott, Minneapolis, MN).

Data of consecutive patients who underwent ViV-TAVR into either failed Trifecta^TM or Epic^TM bioprostheses between October 2015 and June 2020 were retrospectively collected within the International Trifecta and Epic Valve-in-Valve Registry, and analyzed for a primary composite outcome of 30-day mortality and/or coronary obstruction (CO), defined as: (1) CO resulting in myocardial infarction and/or cardiogenic shock, or (2) CO requiring emergent coronary intervention.

A total of 76 patients (49 Trifecta, 27 Epic) with a median age of 80 years (interquartile range [IQR] 75.0; 82.0]) and a median Society of Thoracic Surgeons-score of 5.4 (IQR 4.0; 9.8) were identified. Coronary protection techniques were more frequently performed in Trifecta than Epic patients (29.6% vs. 0%, p = 0.01). The primary composite outcome was observed in three Trifecta versus five Epic cases (6.1% vs. 20%, p = 0.1), which included one case of CO following ViV-TAVR into Epic requiring stenting. Increased rates of patient-prosthesis mismatch (PPM) following valve-in-Epic were found (41.7% vs. 75%, p = 0.08). Survival at a median of 365 days was 86.2% and did not differ between groups (log-rank p = 0.37).

Compared to a stented prosthesis without increased risk of CO, ViV-TAVR into Trifecta prostheses can be performed with low risk of CO and acceptable short-term clinical outcomes. As the rate of post-ViV PPM is substantial for both prostheses, careful patient selection is warranted. (NCT05389631).