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CoreValve and Evolut R
Patients presented below, both with degenerated aortic stentless bioprostheses underwent transcatheter valve-in-valve implantation involving CoreValve 23 in Freestyle aortic root bioprosthesis () and Evolut R in Sorin Pericarbon Freedom stentless prosthesis ().
In note that due to the lack of radiographic landmarks AL diagnostic catheter was used to identify the left coronary artery and provide additional guidance.

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Between 1996 and 2003, 587 patients (mean 75 years) underwent AVR with stentless Medtronic Freestyle® bioprostheses. Follow-up was 99% complete. Determinants of morbidity, mortality, survival time and QoL were evaluated by multiple, time-related, regression analysis. Risk models were built for all sections of the Nottingham Health Profile (NHP): energy, pain, emotional reaction, sleep, social isolation and physical mobility

How Can We Help a Patient With a Small Failing Bioprosthesis?

Bioprosthesis Regular Font: Licensing Options and Technical Information

All operations were performed using standard cardio-pulmonary bypass techniques with systemic normothermia and both antegrade and retrograde hyperkalemic cold blood cardioplegia. The subcoronary implantation was performed using a 4/0 Prolene continuous running suture for both, the first and second suture line. The prosthesis usually was 120° rotated in order to place the Dacron covered muscular part of the implant towards the human non-coronary sinus. Total root implantation was performed using a 4/0 Prolene continuous running suture for the annular implantation and distal anastomoses to the aorta and a 5/0 Prolene suture for coronary ostia re-implantation. The individual surgeons were included into the multivariate models as nominal data. The majority of the stentless valves were implanted by 5 surgeons (surgeons A-E), one surgeon has implanted only 28 valves (surgeon F); a group of younger surgeons, who operated a total of 15 valves, were subsumed as a mixed group M.

Mean scores of the six NHP sections compared to the age- and gender-matched general German population. The QoL after AVR with the stentless bioprosthesis over the follow-up time was compared to the general German population of the same age and gender. Besides from the section "pain" the patients after AVR showed no significant differences to the normal population. Our observation that the patients after AVR have lower values for pain may be explained by misunderstanding of the questionnaires: the patients thought that the question asking for pain mean only cardiac related pain, whereas in the general population all other kinds of pain were included.

Permanent pacing across a tricuspid bioprosthesis

Since the 1950s more than 80 models of prosthetic heart valves have been developed and used

In all cases, patients presented with aortic dysfunction referred both for TAVI in the native annulus and transcatheter aortic valve-in-valve implantation are subjected to widely used multislice contrast-enhanced computed tomography (MSCT). In some cases, other imaging techniques such as three-dimensional transesophageal echocardiography (3D TEE) or MRI are preferred, particularly to avoid exposure to contrast media or to evaluate the function of the prosthetic valve. The assessment of anatomy and aortic valve function coupled with the evaluation of transfemoral approach feasibility (iliofemoral arteries measurements, tortuosity, degree of calcification) () constitute an integral part of the preliminary strategy, which leads to the most appropriate choice of vascular access and – given other patient’s clinical data – rational device selection. Considering the significant presence of coronary artery disease (CAD) among patients with severe aortic stenosis, they are routinely subjected to invasive coronary angiography.
The important issue in ViV planning is the detailed knowledge of the type, design, and size of the surgical bioprosthesis, in particular when considering multiple valves on the market. In general, the bioprosthetic valves can be divided into two categories (stented and stentless) based on the presence of rigid stent into which the leaflets are sutured. Also, the radio-opacity of the valves differs about whether the sewing rings or the stent are visible, and some valves are not visible in the X-rays at all. For stentless valves, it is important to know if the valve was replaced subcronary or the full root-replacement surgery was done. In the setting of stentless valve the risk of coronary obstruction increases [3].

Lotus valve
As one of our patients referred to ViV, a 65-year-old male, previously subjected to coronary artery bypass surgery and aortic valve replacement (Mosaic Medtronic Inc., Minneapolis, Minnesota) was admitted due to dyspnea on slight exertion and mild angina (New York Heart Association grade III, Canadian Cardiovascular Society class II). With suggestive symptoms and transthoracic echocardiography revealing severe aortic valve stenosis (Vmax 4.45m/s; PGmax 79 mmHg; PGmean 58 mmHg), the patient was presented to local interdisciplinary heart team. As considered the too high risk for redo-surgery, after agreement the patient was selected for transcatheter valve-in-valve implantation. Coronary angiography documented non-significant coronary disease. The procedure was performed under general anesthesia from the right femoral access and under fluoroscopic guidance the Lotus 23 Heart Valve (Boston Scientific, Marlborough, Massachusetts) was introduced (). Since there has not been any residual gradient registered and the following echo documented an improvement of hemodynamic features (Vmax 2.9 m/s; PGmax 35 mm Hg; PGmean 15 mmHg) the procedure led to an optimal implantation. After an uneventful recovery at the Intensive Care Unit, followed by the cardiac rehab, the patient was discharged home with proclaimed improvement of symptoms (NYHA class I).

Early failure of bioprosthesis by preserved mitral leaflets
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Early Bioprosthetic Valve Failure JACC: Cardiovascular Imaging

Learning curve of one surgeon concerning transprosthetic gradients after stentless valve implantation [p . The example of one surgeon shows that the mean gradients in subcoronary technique decrease during a time period of 8 years. Beside proper valve sizing and use of total root technique in difficult cases with small aortic roots, the phenomena can be best explained by the increasing ability of the surgeon to fit the valve smoothly into the aortic root and to handle the various aortic root geometries.

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Since the numerous studies have shown the feasibility and safety of the valve-in-valve approach, the transcatheter valve interventions emerged as a valid alternative to redo surgery in patients with failing surgical bioprosthesis. The key to the successful ViV procedure is proper procedural planning (sizing and positioning) as well as avoidance of complications (coronary obstruction, embolization). Due to a significant risk of high residual gradient patients wits smaller surgical valves are not optimal candidates for transcatheter valve implantation. Ongoing registries will provide long-term clinical data.

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Reoperation has been the standard treatment for failed tissue heart valves, but this exposes the patient to a significant risk of morbidity and mortality of 3–7%, but in patients with multiple co-morbidities as high as 30% [3]. It has led to an interest in implanting transcatheter aortic valve implantation (TAVI) prostheses within degenerated surgical prostheses to avoid the surgical risk [4]. The emergence of TAVI in recent years, as well as the transcatheter aortic valve-in-valve implantation – the less invasive treatment for failing bioprosthesis – represents a breakthrough in valve therapy across the World. Considered as an alternative to conventional open heart surgery for high surgical risk, it is indications comprise of bio-prosthetic stenosis, regurgitation or both. Valve-in-valve (ViV) implantation provides less surgical trauma, shortens the procedural time and speeds up the post operation recovery.

Infective Endocarditis in Adults — NEJM

Please cite this article as: T. Gąsior, et al., Aortic valve-in-valve procedures for treatment of failing surgically implanted bioprosthesis, Cor et Vasa 59 (2017) e35–e41 as published in the online version of Cor et Vasa available at

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