Peri-procedural outcome according to VARC-3 criteria and hemodynamic mid-term follow-up after Valve-in-valve transcatheter aortic valve replacement for failed aortic bioprosthesis

Despite the widespread adoption of valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) for patients with failed aortic bioprosthesis, the effectiveness of this treatment for Japanese patients frequently associated with small aortic annuli remains unclear. From December-2011 to October-2022, 41 consecutive patients undergoing VIV-TAVR were enrolled in this study. The endpoints were technical success, device success, early safety, and two-year mortality according to implanted surgical valve size (small valves: 19-mm and 21-mm, n = 23; large valves: 23-mm and 25-mm, n = 18). The patient population had a mean age of 80.5 years, 46.3% male. Technical success, device success, and early safety rates were 100%, 70.7%, and 87.8%, respectively. There was no significant increase in the transprosthetic gradient throughout the follow-up (mean pressure gradient pre-VIV, post-VIV, at one-year, and at two-year; 37.0 mmHg, 16.5 mmHg, 15.0 mmHg, and 12.0 mmHg, respectively). While technical success and two-year mortality were comparable (87.5% vs. 86.7%, log-rank p = 0.816), device success was significantly lower in the small valves than in the large valves (56.5% vs. 88.9%, p = 0.038). Early safety trended lower in the small valves. Valve hemodynamic performance improved in both groups, but severe prosthesis-patient mismatch was more common in the small valves. VIV-TAVR demonstrated acceptable technical performance and relatively low mid-term mortality in this Japanese population, irrespective of aortic annular size. However, device success and early safety were significantly worse in patients with small valves than in those with large valves.