Valve-in-Valve Transcatheter Aortic Valve Replacement: Challenges for Now and the Future

Abstract

The recent years have seen a huge expansion in the number of bioprostheses implanted, and this number is likely to increase further in the future. This is likely to lead to a pandemic of patients requiring reoperation/re-intervention for structural deterioration of the valve. Valve-in-valve transcatheter aortic valve replacement (ViV-TAVR) has become a safe and effective alternative to redo aortic valve surgery and has gained approval for use in high-risk patients with prohibitive operative risk. ViV-TAVR is a complex procedure requiring rigorous planning, technical expertise and patient anatomical appreciation. In this chapter, we examine the evidence supporting the use of ViV-TAVR along with the primary technical issues surrounding this procedure such as: elevated postprocedural gradients, coronary obstruction and valve-related thrombosis. TAVR use is also expanding towards an increasingly young patient profile with extended life expectancy, likely to outlive the implanted bioprosthesis. We therefore also examine the huge current challenge of establishing what is the best lifetime strategy for the management of aortic valve disease in younger patients.