Intra-Annular Versus Supra-Annular Self-Expanding Valves for Valve-in-Valve TAVR

A limitation of Valve-in-Valve (VIV) transcatheter aortic valve replacement (TAVR) is patient-prosthesis mismatch (PPM), which is associated with worse quality of life and heart failure hospitalizations. As such, strategies to avoid PPM are desired. We compared the clinical and hemodynamic results of VIV TAVR with intra-annular self-expanding valves (IA SEV, Navitor, Abbott Vascular) versus supra-annular self-expanding valves (SA SEV, Evolut, Medtronic).

To evaluate the hemodynamics and clinical outcomes of self-expanding valve platforms for VIV TAVR.

Patients were treated at two sites. The primary endpoint was the 30-day mean transvalvular gradient. Secondary endpoints included 30-day effective orifice area (EOA); and key clinical events including major vascular complication, coronary obstruction, 30-day all-cause mortality, stroke, need for reintervention, and new requirement of permanent pacemaker. A linear effects model was fit to adjust for factors related to PPM including surgical valve true inner dimension (TID), balloon post-dilation, body surface area, and etiology of surgical valve failure.

Consecutive patients who underwent VIV TAVR with IA SEV (n = 48) and SA SEV (n = 52) are reported; 42% were women, the mean age was 79.2 ± 6.7 years, and the mean STS Predicted Risk of Mortality was 6.0 ± 4.1%. The mean surgical valve TID was 21.5 ± 1.5 mm. At 30 days, there was no difference in mean transvalvular gradient in IA SEV (10.6 ± 3.6 mmHg) and SA SEV (12.3 ± 6.9, p = 0.44). EOA was slightly larger in IA SEV (1.69 ± 0.6 cm²) than in SA SEV (1.40 ± 0.5 cm², p = 0.04) in the unadjusted analysis. After adjustment, there was no significant effect of IA SEV versus SA SEV (p = 0.28), surgical valve true inner diameter (p = 0.79), or balloon post-dilation (p = 0.37) on gradient. A subset of IA SEV patients who underwent bioprosthetic valve fracture (n = 5) experienced no annular injury, valve leaflet injury, or valve dysfunction at 30 days.

VIV TAVR using an IA SEV was safe in this case series with no difference in hemodynamics between IA SEV and SA SEV. These findings provide support for prospective evaluations of an IA SEV for VIV TAVR.