Incidence of Prosthesis-Patient Mismatch and Short-Term Clinical Outcome after Aortic Valve-in-Valve Implantation Using a Second-Generation Supraannular Self-expanding Valve

Objectives: Transcatheter aortic valve implantation (TAVR) for a degenerated surgical bioprosthesis (ViV) has become an established procedure. Elevated gradients and prosthesis patient mismatch (PPM) have previously been reported in mixed cohorts. We analyzed our single-center experience using the second-generation self-expanding Medtronic Evolut R prosthesis.

Methods: From our database, we identified all patients undergoing ViV using Evolut R prosthesis. Intraprocedural and intrahospital outcomes are reported. PPM was calculated and classified according the European Association of Cardiovascular Imaging (EACVI) recommendations. Calculation of post aortic valve replacement (AVR) PPM was based on company valve data.

Results: Eighty-one patients underwent ViV-TAVR with the Evolut R prosthesis. Mean age was 72 ± 9.8 years, mean STS score was 4 ± 5%, and mean time between initial surgical valve implantation and ViV-TAVR was 10.6 ± 11.7 years. The most commonly treated surgical valves were the Edwards Perimount (48%), St. Jude Trifecta (20%), and Sorin MitroFlow (11%). The mean true internal diameter (ID) of the implanted surgical valves was 21 ± 2.3 mm. Post-AVR, 50.6% had no PPM, 38.3% had moderate PPM, and 2.5% had severe PPM. Seventy-eight patients underwent transfemoral, 2 patients underwent transaortic, and 1 patient underwent trans-subclavian approach. After implantation, the mean transvalvular gradient was reduced significantly from 39.8 ± 12.5 mmHg in patients with prosthetic stenosis to 15.2 ± 9.0 (p < 0.001). One patient had more than mild aortic regurgitation after ViV-TAVR. After ViV-TAVR, 19.8% had no PPM, 22.3% had moderate, and 40.8% had severe PPM. No conversion to surgery was necessary. In five (6.2%) patients, the implantation of a permanent pacemaker was necessary. Major bleeding was reported in five patients (6.2%) and three patients (3.7%) experienced minor bleeding. The rate of device success in our study, according to VARC-2, was 79%. This was due to 17 patients who had postoperative a transprosthetic gradient >20 mm Hg and more than moderate PPM. Estimated Kaplan–Meier survival at 1 year for patients with no PPM was 100%, with moderate PPM was 91%, and with severe PPM was 92%, with no significant difference between the groups.

Conclusion: ViV-TAVR using a supra-annular valve resulted in increased rates of moderate or severe PPM, compared to surgical bioprostheses. Short term survival was not influenced by severity of PPM. Mortality and the need for a permanent pacemaker are considerably lower than reported rates after conventional surgery.