The First Experience of Aortic Valve Repeated Replacement Using the “Valve in Valve” Technique in a Patient With Dysfunction of a Biological Prosthesis

Introduction. Aortic valve replacement in cardiopulmonary bypass with suture fixation of the prosthesis is the “gold standard” in cardiac surgery. Currently, the frequency of use of heart valve bioprostheses is increasing in older patients. Despite all the advantages of using heart valve bioprostheses, this type of prosthesis has a major drawback - it is not durable. In most cases, the reason for the dysfunction of prostheses in the late postoperative period is early calcification of the prosthesis valves or their rupture due to degeneration. With the development of new “gentle” techniques for replacing heart valves, transcatheter aortic valve implantation was introduced into clinical practice. The use of transcatheter aortic valve implantation (TAVI) “valve in valve” for reoperations in older patients is of great interest, since in recent years the procedure has been widely used in clinical practice and shows promising data in patients with high surgical risk.
Aim of study. Show first experience of using a technique «valve in valve» at N.V. Sklifosovsky Research Institute for Emergency Medicine.
Material and methods. The results of surgical treatment of a patient with aortic valve bioprosthesis dysfunction using the TAVI “valve in valve” technique are presented.
Results. The use of the TAVI “valve in valve” method made it possible to perform reprosthetics of the aortic valve (AV) from a transfemoral approach, not to increase the volume of intervention during reoperation, to avoid trauma to the structures of the heart and nearby tissues when accessing the AV in a patient with a high surgical risk.
Conclusion. The use of the TAVI “valve in valve” method in cardiac surgery makes it possible to achieve good immediate and long-term results when it is necessary to replace the AV in patients with a high surgical risk.

1. Gummert JF, Funkat A, Beckmann A, Schiller W, Hekmat K, Ernst M, et al. Cardiac surgery in Germany during 2007: a report on behalf of the german society for thoracic and cardiovascular surgery. Thorac Cardiovasc Surg. 2008;56(6):328–336. PMID: 18704854 https://doi.org/10.1055/s-2008-1038756

2. Brown JM, O’Brien SM, Wu C, Sikora JA, Griffith BP, Gammie JS. Isolated aortic valve replacements in North America comprising 108,687 patients in 10 years: changes in risk, valve types, and outcomes in the society of thoracic surgeons national database. J Thorac Cardiovasc Surg. 2009;137(1):82–90. PMID: 19154908 https://doi.org/10.1016/j.jtcvs.2008.08.015

3. Chan V, Lam B-K, Rubens FD, Hendry P, Masters R, Mesana TG, et al. Long-term evaluation of biological versus mechanical prosthesis use at reoperativeaortic valve replacement. J Thorac Cardiovasc Surg. 2012;144(1):146–151. PMID: 21962842 https://doi.org/10.1016/j.jtcvs.2011.08.041

4. Rahimtoola SH. Choice of prosthetic heart valve for adult patients. J Am Coll Cardiol. 2003;41(6):893–904. PMID: 12651032 https://doi.org/10.1016/S0735-1097(02)02965-0

5. Barbarash LS, Zhuravleva IYu. Bioprosthetic Heart Valve Evolution: Two Decades of Advances and Challenges. Complex Issues of Cardiovascular Diseases. 2012;(1):4–11. (in Russ.) https://doi.org/10.17802/2306-1278-2012-1-4-11

6. Jamieson WR, Germann E, Aupart MR, Neville PH, Marchand MA, Fradet GJ. 15-year comparison of supra-annular porcine and PERIMOUNT aortic bioprostheses. Asian Cardiovasc Thorac Ann. 2006;14(3):200–205. PMID: 16714695 https://doi.org/10.1177/021849230601400306

7. Orlovskiy PI, Gritsenko VV, Yukhnev AD, Evdokimov SV, Gavrilenkov VI. Iskusstvennye klapany serdtsa. Saint Petersburg: OLMA Media Grupp Publ.; 2007. (in Russ.).

8. Hoffmann G, Lutter G, Cremer J. Durability of bioprosthetic cardiac valves. Dtsch Arztebl Int. 2008;105(8):143–148. PMID: 19633780 https://doi.org/10.3238/arztebl.2008.0143

9. Bourguignon T, Bouquiaux-Stablo A-L, Candolfi P, Mirza A, Loardi C, May M-A. Very long-term outcomes of the Carpentier-Edwards Perimount valve in aortic position. Ann Thorac Surg. 2015;99(3):831–837. PMID: 25583467 https://doi.org/10.1016/j.athoracsur.2014.09.030

10. Bokeriya LA, Gudkova RG, Milievskaya EB. Serdechnososudistaya khirurgiya-2016: bolezni i vrozhdennye anomalii sistemy krovoobrashcheniya. Moscow: NMITsSSKh im. A.N. Bakuleva MZ RF Publ.; 2017. (in Russ.)

11. Sokolov VV, Kovalyov AI, Vladimirov VV, Ivanov IV, Bikbova NM. Perceval S Sutureless Prosthesis in Aortic Valve Replacement. Russian Sklifosovsky Journal Emergency Medical Care. 2019;8(1):87–92. https://doi.org/10.23934/2223-9022-2019-8-1-87-92

12. Davierwala PM, Borger MA, David TE, Rao V, Maganti M, Yau TM. Reoperation is not an independent predictor of mortality during aortic valve surgery. J Thorac Cardiovasc Surg. 2006;131(2):329–335. PMID: 16434261 https://doi.org/10.1016/j.jtcvs.2005.09.022

13. Kumar P, Athanasiou T, Ali A, Nair S, Oz BS, DeSouza A, et al. Redo aortic valve replacement: does a previous homograft influence the operative outcome? J Heart Valve Dis. 2004;13(6):904–913. PMID: 15597580

14. Kirsch EW, Radu NC, Mekontso-Dessap A, Hillion M-L, Loisanceet D. Aortic root replacement after previous surgical intervention on the aortic valve, aortic root, or ascending aorta. J Thorac Cardiovasc Surg. 2006;131(3):601–608. PMID: 16515911 https://doi.org/10.1016/j.jtcvs.2005.11.007

15. Campanella C, Hider CF, Duncan AJ, Bloomfield P. Must the mitral valve always be removed during prosthetic replacement? Ann Thorac Surg. 1990;49(1):167–168. PMID: 2297269 https://doi.org/10.1016/0003-4975(90)90389-N

16. Raffa H, Al-Ibrahim K, Sorefan AA, Narayanan L. Superimposition of a mechanical valve on an impacted aortic bioprosthesis. Tex Heart Inst J. 1991;18(3):199–201. PMID: 15227480

17. Sokolov VV, Kovaleva EV, Boychevskaya EI, Myakishev VB, Semenovskiy ML. Povtorenie operatsii posle protezirovaniya klapanov serdtsa. Russian Journal of Surgery. 1996;(3):79–83. (in Russ.).

18. Cribier A. Development of transcatheter aortic valve implantation (TAVI): А 20-year odyssey. Arch Cardiovasc Dis. 2012;105(3):146–152. PMID: 22520797 https://doi.org/10.1016/j.acvd.2012.01.005

19. Wenaweser P, Buellesfeld L, Gerckens U, Grube E. Percutaneous aortic valve replacement for severe aortic regurgitation in degenerated bioprosthesis: the first valve in valve procedure using the Corevalve Revalving system. Catheter Cardiovasc Interv. 2007;70(5):760–764. PMID: 17932876 https://doi.org/10.1002/ccd.21300

20. Kokov LS, Sokolov VV, Parkhomenko MV, Muslimov RS, Bulanova MV, Bikbova NM. Valve-in-valve transcatheter aortic valve replacement on a self-expandable nitinol frame due to degeneration of primary bioprosthetic valve cusps. Clinical case of a high-risk surgical female patient. Russian Journal of Transplantology and Artificial Organs. 2020;22(3):107–114. https://doi.org/10.15825/1995-1191-2020-3-107-114

21. Hirose H, Gill IS, Lytle BW. Redo-aortic valve replacement after previous bilateral internal thoracic artery bypass grafting. Ann Thorac Surg. 2004;78(3):782–785. PMID: 15336991 https://doi.org/10.1016/j.athoracsur.2004.02.035

22. Pineda AM, Santana O, Reyna J, Sarria A, Lamas GA, Lamelas J. Outcomes of reoperative aortic valve replacement via right mini-thoracotomy versus median sternotomy. J Heart Valve Dis. 2013;22(1):50–55. PMID: 23610989

23. Seiffert M, Franzen O, Conradi L, Baldus S, Schirmer J, Meinertz T, et al. Series of transcatheter valve-in-valve implantations in high-risk patients with degenerated bioprostheses in aortic and mitral position. Catheter Cardiovasc Interv. 2010;76(4):608–615. PMID: 20506236 https://doi.org/10.1002/ccd.22618

24. Webb J, Wood D, Ye J, Gurvitch R, Masson J-B, Rodés-Cabau J, et al. Transcatheter valve-in-valve implantation for failed bioprosthetic heart valves. Circulation. 2010;121(16):1848–1857. PMID: 20385927 https://doi.org/10.1161/CIRCULATIONAHA.109.924613

25. Piazza N, Bleiziffer S, Brockmann G, Hendrick R, Deutsch M-A, Opitz A, et al. Failing Surgical Aortic Bioprosthetic Valve: From Concept to Clinical Application and Evaluation (Part 2). J Am Coll Cardiol Interv. 2011;4(7):733–742. PMID: 21777880 https://doi.org/10.1016/j.jcin.2011.05.007

26. Ussia GP, Barbanti M, Ramondo A, Petronio AS, Ettori F, Santoro G, et al. The Valve-in-Valve Technique for Treatment of Aortic Bioprosthesis Malposition: An Analysis of Incidence and 1-Year Clinical Outcomes from the Italian Core Valve Registry. J Am Coll Cardiol. 2011;57(9):1062–1068. PMID: 21349397 https://doi.org/10.1016/j.jacc.2010.11.019

27. Bapat V, Attia R, Redwood S, Hancock J, Wilson K, Young C, et al. Use of transcatheter heart valves for a valve-in-valve implantation in patients with degenerated aortic bioprosthesis: Technical considerations and results. J Thorac Cardiovasc Surg. 2012;144(6):1372–1380. PMID: 23140962 https://doi.org/10.1016/j.jtcvs.2012.07.104