Along with the coming of aged society, the prevalence of heart valvular disease is significantly increasing, and the use of bioprosthetic valves for treating patients with severe valve disease has increased over the last two decades. As a consequence, a growing number of patients with surgical bioprosthesis degeneration is predicted in the near future. In this setting, valve-in-valve (ViV) transcatheter aortic/mitral valve replacement (TAVR/TMVR) has emerged as an alternative to redo surgery. A deep knowledge of the mechanism and features of the failed bioprosthetic heart valve is pivotal to plan an adequate procedure. Multimodal imaging is fundamental in the diagnostic and pre-procedural phases. The immediate and mid-term clinical and hemodynamic results have demonstrated the safety and feasibility of ViV techniques, but the development of these techniques faces several specific challenges, such as coronary obstruction, potential post-procedural mismatch and leaflet thrombosis. This article reviews the current status and prospects of ViV-TAVR technology in the treatment for biological valve degeneration, and suggests that ViV-TAVR should be promoted and implemented in existing medical centers with good surgical aortic valve replacement experience, so as to provide better treatment for patients.
Objective To summarize the clinical experience and mid-term outcomes of transcatheter aortic valve implantation valve-in-valve (TAVI-ViV) for failed surgical bioprostheses in the aortic position. Methods Patients who underwent TAVI-ViV procedures at Tianjin University Chest Hospital between January 2019 and January 2025 were consecutively enrolled. Baseline characteristics, procedural details, and postoperative hemodynamic performance were collected and analyzed. Early postoperative and follow-up valve hemodynamics were evaluated, and surgical experiences were summarized. The primary endpoint was all-cause mortality, and the secondary endpoint was severe prosthetic valve stenosis. Results A total of 45 patients were included, with a mean age of (68.38±7.72) years and an average interval between surgeries of (11.00±3.67) years. The Society of Thoracic Surgeons (STS) score was 6.80% (4.29%, 8.21%). The procedural success rate was 97.78% (44/45), with one case aborted due to coronary obstruction. The mean implantation depth was (6.87±3.45) mm, the annular expansion rate ranged from 10% to 40%, and the stent crown compression rate varied from 0% to 42%. The median follow-up duration was 21 months, with 27 patients completing the 2-year follow-up. At 2 years postoperatively, the overall follow-up rate was 92.59% (25/27), and the echocardiographic follow-up rate was 66.67% (18/27). The all-cause mortality rate was 7.41% (2/27). The mean peak aortic valve velocity was 2.96±0.69 m/s, the mean transvalvular gradient was (21.83±10.98) mm Hg, and 3 patients exhibited velocities ≥4 m/s (indicating severe stenosis). The regression analysis showed that the implant depth deviation [β=0.41, SE=0.18, OR=1.51, 95%CI (1.06, 2.30), P=0.024］, the compression rate of the corona [β=2.48, OR=11.93, 95%CI (1.21, 122.40), P=0.034], and the enlargement rate of the annulus [β=1.96, OR=7.13, 95%CI (1.28, 35.50), P=0.026] were the independent predictors of high flow velocity after surgery. Conclusion The optimal implantation depth for TAVI-ViV using a self-expanding valve system is 4 to 5 mm. When the annular expansion rate approaches 10%, hemodynamic performance can be significantly improved. The degree of crown compression in the valve stent is strongly correlated with elevated postoperative transvalvular gradients.
Objective To investigate the biological and biomechanical characteristics of acellular porcine aortic valve with dye mediated photo oxidation so that a new and better bioprosthetic valve materials can be obtained. Methods Thirty porcine aortic valves were divided into three groups with random number table. Acellular valves (n=10) were stabilized by dye mediated photo oxidation in dye mediated photo oxidation group; acellular valves (n=10) were stabilized by glutaraldehyde in glutaraldehyde group; and acellular valves (n=10) were acellularized only in acellular valves group. Thickness, appearance, histology, water content, shrinkage temperature, breaking strength and soluble protein level of acellular porcine aortic in three groups were tested respectively. Results There were light blue, soft, flexible and unshrinking valves in dye mediated photo oxidation group. Compared to valves in glutaraldehyde group, valves in dye mediated photo oxidation group had lighter thickness（0.26±0.09mm vs. 0.38±0.08mm，Plt;0.05）, more water content（86.30%±4.03% vs. 71.10%±3.23%，Plt;0.05）, and lower shrinkage temperature （76.30±0.70℃ vs. 87.70±0.30℃，Plt;0.05）; while these indexes had no statistically significant differences compared to those in acellular valves group. At the same time, compared to valves in acellular valves group, valves in dye mediated photo oxidation group had more breaking strength（17.33±2.65 mPa vs. 9.11±0.95 mPa，Plt;0.05） and lower soluble protein level（0.039%±0.013% vs. 0.107%±0.024%，Plt;0.05）; while these indexes had no statistically significant differences compared to those in glutaraldehyde group. Conclusion Acellular porcine aortic valve stabilized by dye mediated photo oxidation has nice biological and biomechanical characteristics.
Biological valves can lead to structural valve degeneration (SVD) over time and due to various factors, reducing their durability. SVD patients need to undergo valve replacement surgery again, while traditional open chest surgery can cause significant trauma and patients often give up treatment due to intolerance. Research has shown that as an alternative treatment option for reoperation of thoracic valve replacement surgery, redo-transcatheter aortic valve replacement for SVD is safe and effective, but still faces many challenges, including prosthesis-patient mismatch, high cross valve pressure difference, and coronary obstruction. This article aims to review the strategies, clinical research status and progress of redo-transcatheter aortic valve replacement in SVD patients.
Commissural misalignment of biological valve and autologous valve during transcatheter aortic valve replacement may affect the filling of coronary artery, reduce the feasibility of redo-aortic valve intervention and damage the valve function, which will adversely affect long-term prognosis of patients. Some studies have obtained achievement by changing the axial direction of valve and using individualized computer simulation technology to improve the alignment technology. However, there are still many unknown problems about the impact of commissural misalignment on patients, and accurate commissural alignment techniques still need to be further explored. This article systematically expounds the possible impact of commissural misalignment between biological valve and autologous valve in transcatheter aortic valve replacement, possibly effective accurate commissural alignment techniques and related research progress.
Objective To summarize the short-term results of valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) in the treatment of bioprosthetic valve failure after aortic valve replacement. Methods We reviewed the clinical data of patients who underwent ViV-TAVI from 2021 to 2022 in the First Affiliated Hospital of Zhengzhou University. The valve function was evaluated by echocardiography before operation, immediately after operation and 3 months after operation. The all-cause death and main complications during hospitalization were analyzed. Results A total of 13 patients were enrolled, including 8 males and 5 females with a mean age of (65.9±8.5) years, and the interval time between aortic valve replacement and ViV-TAVI was (8.5±3.4) years. The Society of Thoracic Surgeons mortality risk score was 10.3%±3.2%. None of the 13 patients had abnormal valve function after operation. The mean transvalvular pressure gradient of aortic valve was decreased (P<0.001), the peak flow velocity of aortic valve was decreased (P<0.001), and the left ventricular ejection fraction was not changed significantly (P=0.480). There were slight perivalvular leakage in 2 patients and slight valve regurgitation in 3 patients. Three months after operation, the mean transvalvular pressure difference and peak flow velocity of aortic valve in 12 patients were significantly decreased compared with those before operation (P≤0.001). Conclusion This study demonstrates that ViV-TAVI for the treatment of bioprosthetic valve failure after aortic valve replacement is associated with favorable clinical and functional cardiovascular benefits, the short-term results are satisfactory.
ObjectiveTo study the biocompatibility of bioprosthetic heart valve material with a non-glutaraldehyde-based treatment, and to provide the safety data for the clinical application. MethodsAll the tests were conducted according to GB/T16886 standards. The in vitro cytotoxicity was determined by methyl thiazolyl tetrazolium assay. Fifteen guinea pigs were divided into a test group (n=10) and a control group (n=5) in the skin sensitization test. Three New Zealand white rabbits were used in the intradermal reactivity test. Five sites on both sides of the rabbit back were set as test sites and control sites, respectively. In the acute systemic toxicity test, a total of 20 ICR mice were randomly assigned to 4 groups: a test group (polar medium), a control group (polar medium), a test group (non-polar medium) and a control group (non-polar medium), 5 in each group. Forty SD rats were divided into a test group (n=20) and a control group (n=20) in the subchronic systemic toxicity test. ResultsThe viability of the 100% extracts of the bioprosthetic heart valve material with a non-glutaraldehyde-based treatment was 75.2%. The rate of positive reaction was 0.0%. The total intradermal reactivity test score was 0. There was no statistical difference in the body weight between the test group and control group in the acute systemic toxicity test. There was no statistical difference in the body weight, organ weight, organ weight/body weight ratio, blood routine test or blood biochemistry between the test group and control group in the subchronic systemic toxicity test. ConclusionThe bioprosthetic heart valve material with a non-glutaraldehyde-based treatment has satisfying biocompatibility, which conforms to relevant national standards. The material might be a promising material for application in valve replacement.
Heart valve replacement is the major surgical treatment of severe valvular diseases. Due to the durability and reoperation-free, mechanical valves are widely used. Bioprosthesis valves became popular recently because of long service life and no demand for lifelong anticoagulation. However, how to choose the appropriate prosthetic heart valves, especially the application of bioprosthesis valves for patients at 55 to 65 years is still a major problem. This review focuses on more effective and scientific basis for rational choice of mechanical and bioprosthesis valve.