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  • Valve Underexpansion in ViV TAVR Produces Worse Hemodynamic Outcomes – Single-Center Study

    Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) often produces results in underexpansion of the functional portion of transcatheter heart valve (THV) prostheses, particularly when these are deeply implanted, which leads to worse hemodynamics, a new study shows.

    These findings were reported by Miho Fukui, MD, PhD, of the Minneapolis Heart Institute Foundation, and colleagues in a manuscript published Monday online and in the March 13 issue of JACC: Cardiovascular Interventions.

    Select patients typically undergo ViV TAVR for reintervention after surgical bioprosthetic valve degeneration. THV deformation is not well-studied, so the investigators sought to examine the relationship between deformation of THV in ViV TAVR and hemodynamics 30 days post-implantation.

    ViV TAVR with self-expanding Evolut prostheses (Medtronic) outcomes were examined in 53 patients (median age at ViV TAVR = 79 years [interquartile range: 72-85]; 62.3% male) at the authors’ institution. Cardiac computed tomography was used to observe THV deformation at 30 days post-procedure and correlated with the echocardiographic hemodynamic data. Common comorbidities included diabetes mellitus (30.2%), hypertension (71.7%), atrial fibrillation/flutter (37.7%) and coronary artery disease (66.0%).

    The functional portion of the implanted ViV prostheses (>90%) was almost completely expanded in 30.2% of patients. Larger neosinus volume due to greater expansion of the functional portion of THV was related to in-procedure absence of polymer surgical frame, higher implantation and use of balloon aortic valvuloplasty or bioprosthetic valve fracture (all p < 0.05).

    On echocardiography at 30 days, the inflow frame was not associated — but underexpansion of the function portion of THV was associated — with the mean gradient and effective orifice area. This was accounted for with and without adjustment for size of the THV and surgical heart valve.

    The authors noted some study limitations, including that the study did not involve other THV platforms outside self-expanding prostheses (Evolut) and only looked at TAVR in surgical aortic valve replacement. They added that the number of patients in the study was relatively small.

    Overall, the investigators concluded that techniques like higher implantation and balloon postdilatation may help with issues arising from THV underexpansion during ViV TAVR, as underexpansion of THV prostheses is associated with worse hemodynamics after ViV TAVR.

    In an accompanying editorial, Frédéric Beaupré, MD, and Philippe Garot, MD, of the Pitié Salpêtrière (AP-HP), Paris, compared the history of ViV TAVR to the current study.

    “The investigators should be congratulated for this well-designed study that, although small in size, brings valuable information on the deformability of EVOLUT devices in a ViV setting,” wrote the editorialists. Beaupré and Garot also said practitioners should be cautious due to the small size of the study.

    “One thing is certain: the volume of ViV procedures will increase in the coming years, and it is mandatory to sharpen our understanding of the relationship between the transcatheter valve, the degenerated prosthesis, and the patient anatomy,” the editorialists said.

    They concluded that patients and their providers should continue to remember the risks of the procedure, while tailoring each case to “Achieve the best long-term results for the patient.”


    Fukui M, Sorajja P, Cavalcante JL, et al. Deformation of Transcatheter Heart Valve Following Valve-in-Valve Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2023;16:515-526.

    Beaupré F, Garot P. PCSK9: 3 Ways to Mitigate the Risk of Transcatheter Heart Valve Underexpansion and Dysfunction in Valve-in-Valve TAVR. J Am Coll Cardiol 2023;16:527-529.

    Image Credit: mehmet –

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