Redo transcatheter aortic valve replacement (TAVR) with the SAPIEN 3 (S3) valve presents challenges, according to a new analysis of patient data that also shows downsizing is frequent, and under-expansion may lead to suboptimal hemodynamics. The research letter, published online in JACC: Cardiovascular Interventions, highlights the complexities of redo TAVR, particularly in cases involving failed Evolut devices. Led by Alejandro Travieso, MD, from Copenhagen University Hospital, Denmark, the research team noted that as transcatheter aortic valve replacement (TAVR) expands to younger and lower-risk patients with longer life expectancies, redo TAVR is becoming increasingly necessary. “However, redo TAVR procedures present technical challenges, particularly regarding valve sizing and the interaction between different valve types,” the authors said, adding that the need for optimal valve expansion and structural integrity, combined with the complexity of valve-in-valve configurations, makes procedural planning critical. “Mismatches between the first and second valve types can impact long-term outcomes, making careful consideration of valve sizing and positioning essential,” they noted, adding that the findings from their analysis “provide important insights into the structural and functional outcomes of redo TAVR and may help guide future procedural strategies.” Study details Travieso and colleagues analyzed the outcomes of redo TAVR using the SAPIEN 3 (S3) (Edwards Lifesciences) as the second transcatheter aortic valve (TAV-2), focusing on valve sizing, structural behavior, and hemodynamic performance, which are key for procedural success. The team performed a detailed post-TAVR cardiac CT analysis of 30 consecutive patients who underwent redo TAVR with S3, and the impact of valve sizing strategy (annular sizing versus downsizing) on valve expansion, deformation, eccentricity and transprosthetic gradients was examined. Patients were stratified into 3 groups based on valve-in-valve configuration and redo S3 position: 1) S3-in-S3 (n = 14); 2) S3-in-Evolut high (S3 outflow at node 6) (n = 6) (Medtronic) and 3) S3-in-Evolut low (S3 outflow at node 4) (n = 10). Analysis found that S3 downsizing is common in red TAVR, with 23% (n = 7) patients downsized the redo S3 prosthesis. Such downsizing was most frequently recorded in high S3-in-Evolut configurations (n = 4 of 6; 66.7%) scenarios, while downsizing was less frequent for S3-in-S3 (n = 2 of 12; 16.7%) and low S3-in-Evolut (n = 1 of 9; 11.1%). “This reflects the complexity of valve-in-valve procedures, in which mismatches between the index Evolut valve and the redo S3 prosthesis may necessitate downsizing for adequate function, particularly in high S3-in-Evolut implant positions,” said Travieso and colleagues. Furthermore, the team noted that S3 valves implanted within Evolut frames, particularly those implanted low, exhibited significant under-expansion. “Overall valve expansion was lowest in the low S3-in-Evolut group across both annular sizing and downsizing (83%-85% vs 88%-93% in the other redo TAVR configurations),” they reported, noting that S3 outflow expansion was further reduced to 76% in downsized low S3-in-Evolut cases - raising concerns about the durability and long-term outcomes of such procedures. Travieso and colleagues also found that the deformation index and eccentricity index demonstrated acceptable structural integrity for S3-in-S3 cases, noting that in S3-in-Evolut configurations with annular sizing, high implants exhibited the highest deformation index (1.11). Meanwhile low implants had the highest eccentricity index (0.43), they said, noting that such S3 stent frame distortion could be linked to the altered hemodynamics observed in these cases. “Hemodynamic performance was suboptimal in S3-in-Evolut cases, particularly with annular sizing for high S3-in-Evolut and downsizing for low S3-in-Evolut,” they added, noting that a similar trend was observed in effective orifice area, with the lowest values seen in high S3-in-Evolut with annular sizing (1.3 cm2) and in low S3-in-Evolut with downsizing (1.2 cm2). Such suboptimal valve hemodynamic performance may result from potential under-expansion and leaflet pinwheeling in annular sizing for high S3-in-Evolut implants and valve mismatch in downsized low S3-in-Evolut implants, the team suggested. “This study highlights the complexities of redo TAVR. TAV-2 downsizing is not uncommon, particularly in the case of high S3-in-Evolut implants, and under-expansion appears to be a concern, especially in low S3-in-Evolut configurations,” concludedTravieso and colleagues. Source: Travieso A, Zaid S, Norgaard BL, et al. Impact of Valve Sizing and Positioning on Expansion and Hemodynamics in Redo TAVR With SAPIEN 3. JACC Cardiovasc Interv 2024; Online Ahead of Print Image Credit: Edwards Lifesciences – heartvalves.com