Structural Heart Interventions

What to know when planning for a second TAVI valve

Recent guidelines on valvular heart disease in Europe and the USA have expanded the indications for transcatheter aortic valve implantation (TAVI) to younger patients and those at lower surgical risk with severe symptomatic aortic stenosis—a change that is likely to herald a substantial increase in TAVI procedures worldwide, including “redo” procedures. Giuseppe Tarantini (University of Padua Medical School, Padua, Italy) tells Cardiovascular News why this topic is increasing focus, and details the fundamentals of planning for TAVI reintervention.

With TAVI being performed in younger patients, can we expect to see more redo procedures in future?

This is an extremely relevant topic, as now the mean age of TAVI patients, particularly in the USA, is around 70 years of age. For most of these subjects, one transcatheter heart valve will not be enough. In fact, if we consider the patients’ life expectancy and the “supposed” prosthesis durability of about 10 years, many of these subjects will outlive their transcatheter heart valve, meaning that they will need reintervention. At that point, they will be likely too old to consider TAVI explant and redo TAVI—if feasible—will be the preferable option.

What do data tell us about the outcomes of redo TAVI?

Available data on redo TAVI come from two large international registries, with patients treated at high volume (i.e. expert) centres. First of all, redo TAVI represents only 0.33% of the aortic transcatheter procedures. Survival rate at 30 days was around 98%, with low rates of stroke of 1‒2%, coronary obstruction (1%) and pacemaker implantation (10%). But, we should keep in mind that these are highly selected patients treated at tertiary care hospitals and thus we: 1) do not know how many patients were denied redo TAVI because it was believed to be unfeasible based on preprocedural computed tomography (CT) planning, 2) do not know if these results are reproducible in lower volume centres.

Are there studies currently ongoing and what do we hope to learn?

There are many registries ongoing on this topic, promoted by major transcathether heart valve manufacturers. I am the principal investigator of a European multicentre prospective registry looking at redo-TAVI with a balloon-expandable valve. From these studies we expect to learn the timing and failing mechanism of transcatheter aortic valves, the incidence of redo TAVI unfeasibility and the real world outcomes of this procedure. Moreover, we will try to understand what is the best operative practice in doing these procedures, for which I have written, together with a group of international experts, an operative manual. Finally, these studies will provide us with the real world short and mid-term outcomes of redo TAVI and, for instance, the clinical impact of leaflets’ overhanging.

How does planning and executing a redo procedure differ from a first implant?

Planning redo TAVI is more complex than planning TAVI in native aortic valves. In fact, operators need