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In recent years the trend towards surgical bioprosthetic valve implantation, especially among young patients, has increased in order to avoid anticoagulant therapy. The patient’s age remains one of the leading risk factors for valve dysfunction. Gold standard for treating such diseases was surgical reintervention until the development of transcatheter heart valves. By 2050 the annual number of patients undergoing surgical bioprosthetic valve implantation is expected to triple from an average of 290,000 in 2003 to over 850,000. This study presents the literature review of Valve in Valve and Valve in Ring procedures, as well as our experience in ViV and ViR transcatheter valve implantation.

Open in new tab Download slide Open in new tab Download slide OBJECTIVES Long-term durability of surgical bio-prostheses is a key factor, especially in the era of transcatheter aortic valve replacement. We compared the incidence of structural valve deterioration (SVD) between patients undergoing surgical aortic valve replacement (SAVR) with the Trifecta (Abbott Laboratories, Abbott Park, IL, USA) or the Intuity valve (Edwards Lifesciences, Irvine, CA, USA). METHODS Between April 2010 and May 2020, 1118 patients underwent SAVR with the Trifecta (n  = 346) and the Intuity (n  = 772) valve at a single centre. A total of 1070 patients (Trifecta n  = 298, Intuity n  = 772) were analysed after the exclusion of patients with pure regurgitation and endocarditis. Retro- and prospective echocardiographic and clinical follow-up was performed. Cox proportional hazards regression models were performed to identify prognostic factors for SVD, aortic re-interventions and mortality. RESULTS With 27 cases (Trifecta n = 23, Intuity n = 4) of SVD observed, cumulative incidence of SVD was significantly higher in the Trifecta cohort (P < 0.001). Implantation of a Trifecta valve [hazard ratio (HR) 11.20; 95% confidence interval 3.79–33.09], log-transformed preoperative creatinine (HR 2.47; 1.37–4.44) and sex (male HR 0.42; 0.19–0.92) emerged as prognostic factors of SVD. A significantly higher cumulative incidence of re-interventions was observed in the Trifecta cohort (P  = 0.004) and valve type was an independent time-varying risk factor (HR at 12 months 2.78; 95% confidence interval 1.42–5.45). Overall, no significant differences in all-cause mortality were observed between the groups (log-rank test: P  = 0.052). CONCLUSIONS SVD was significantly more frequent in patients receiving a Trifecta valve and its implantation was an independent risk factor for the occurrence of SVD and aortic valve re-interventions. This comparative analysis of 2 low-gradient bioprosthesis put the long-term durability of the Trifecta valve in question and need to be taken into consideration when performing bioprosthetic SAVR. [ABSTRACT FROM AUTHOR]

Aim: to assess the contribution of primary tissue failure, calcification, bacterial contamination and pannus to bioprosthetic valve dysfunction.Materials and methods. To evaluate degenerative changes of the «UniLine» bioprosthesis explanted from the mitral position with macroscopic examination, light and scanning electron microscopy, and micro-computed tomography (micro-CT). Light microscopy was used to analyze cell composition, the presence of bacteria, the localization of calcific deposits and recipient cells. Scanning electron microscopy allowed confirming the presence of bacteria. Micro-CT was used to evaluate the deformation of the bioprosthetic elements, the distribution of calcific deposits and their volume in the valve tissue.Results. The presence of pannus, calcification, primary tissue failure and bacterial contamination were found among the causes leading to bioprosthetic dysfunction. Prosthetic leaflets showed pannus growth from the inflow tract. Excessive circumferential pannus extended into outflow tract. Calcific deposits were mostly localized in the commissural zone and the central portion of the leaflets. The total volume of calcification accounted for 1/3 of the bioprosthetic tissue component. The relationship between calcification and stress-strain properties of the bioprosthetic elements has been indicated. The asymmetric deformation of the bioprosthetic stent frame and leaflets with 1.5-fold thickening of the last has been found. The areas with loose and fragmented collagen and elastic fibers contained red blood cells and neutrophils. Endothelial cells and fibroblastic cells were present in the outer surface layers. There were no signs of calcification in the areas accumulating cells and bacteria.Conclusion. We can assume that primary tissue failure, calcification, bacterial contamination and pannus independently contribute to the onset of bioprosthetic heart valve dysfunction.

Aim. To assess the contribution of pannus and calcification to the development of bioprosthetic valve dysfunction after tricuspid valve replacement in a pediatric patient.Materials and methods. A 3-month-old patient presented with tricuspid valve dysplasia and grade 4 tricuspid insufficiency underwent tricuspid valve replacement with the bioprosthesis «PeriCor» (ZAO «NeoKor», Russian Federation). The patient at the age of 6 years required a redo tricuspid valve replacement 5 years 8 months after initial surgery. Degenerative changes of the dysfunctional bioprosthetic valve explanted from the tricuspid position were assessed using macroscopic description and light microscopy. Cellular composition, the presence of bacteria, colocalization of calcifications with recipient cells were analyzed. The distribution of calcifications and their volume in the biomaterial tissue were estimated using microcomputer tomography imaging (micro-CT).Results. Bioprosthetic valve dysfunction was mainly caused by the pannus formation which was shown to encapsulate the anterior leaflet, resulting in its total failure and severe stenosis (reduced effective orifice area). There were no signs of ruptures and perforations in the valve tissues found. All leaflets were shown to contain predominantly fibroblastic cells and single blood cells, mainly located in the surface layers of the leaflets in the regions without any signs of calcification. Bacteria staining was negative for all types of the studied biomaterials. Calcifications were present in all xeno-tissue elements of the explanted bioprosthesis (i.e. leaflets, aortic segment, and pericardium). In addition, calcifications were also found in pannus growing during a functioning bioprosthetic valve. Calcifications were predominantly located in the co-optation and commissure zones of the leaflets. Importantly, massive calcifications were observed around the bioprosthetic stent frame. The total volume of calcification accounted for 1/3 of the biological component of the bioprosthesis (729 mm3).Conclusion. According to the data obtained in this study, we may conclude that the primary cause of the bioprosthesis failure was the growth of connective tissues, resulting in pannus-related dysfunction, rather than severe calcification of all bioprosthetic components. One may assume that bioprosthetic dysfunction is related to the peculiarity of the inflammatory response of the preschool patient. However, this typeof dysfunctions requires further investigation.

Bioprosthetic dysfunction, bioprosthetic valve failure, structural valve deterioration, hemodynamic valve deterioration Keywords: bioprosthetic dysfunction; bioprosthetic valve failure; hemodynamic valve deterioration; structural valve deterioration EN bioprosthetic dysfunction bioprosthetic valve failure hemodynamic valve deterioration structural valve deterioration 4293 4294 2 01/02/23 20221201 NES 221201 The last decade has seen an exceptional increase in the number of implanted valvular bioprostheses, due to the increasing prevalence of valve disease in an aging population, and the advent of transcatheter technologies and minimally invasive approaches in open-heart surgery. Seven bioprosthetic valve failures needing cardiac reoperation were present in this patients' series: 4 Magna Ease (1.2%), 2 Epic (1.3%), and 1 Trifecta (0.8%), with no statistically significant difference between them. [Extracted from the article]

Aims: Bioprosthetic valve dysfunction (BVD) is a major concern regarding transcatheter aortic valve implantation (TAVI) durability. We aimed to assess incidence, correlates, causes, and outcome of early to mid-term BVD after TAVI in relation to patient's life expectancy., Methods and Results: Consecutive TAVI recipients (2007-20) with a follow-up ≥1 year were prospectively included. BVD and bioprosthetic valve failure (BVF) were assessed according to Valve-Academic-Research-Consortium-3. BVD/BVF and all-cause death served as endpoints. Average life expectancy was calculated from National Open Health Data and patients were stratified according to tertiles (1st: <6.85 years, 2nd: 6.85-9.7 years, 3rd: >9.7 years). Of 1047 patients (81.6 ± 6.8 years old, EuroSCORE II 4.5 ± 2.5), ≥2 follow ups were available from 622 (serial echo cohort). After a median echo follow up of 12.2 months, incidence rates of BVD/BVF were 8.4% (95% confidence interval 6.7-10.3), and 3.5% (2.5-4.9) per valve-year, respectively, without differences between life expectancy tertiles. The incidence of BVD was two-fold higher within the first year of implant (9.9% per valve-year) vs. beyond (4.8% per valve-year). Valve-in-valve procedure and residual stenosis, but not age/life expectancy predisposed for BVD. BVD/BVF were independently associated with outcome for patients in the first [adjusted hazard ratio (AHR) 1.72 (1.06-2.88)/2.97 (1.72-6.22)] and second [AHR 1.96 (1.02-3.73)/2.31 (1.00-5.30)], but not the third tertile of life expectancy (P = n.s.)., Conclusions: In this large prospective observational cohort, early to mid-term BVD after TAVI occurred at the same rate across the spectrum of life expectancy and was associated with increased mortality in patients with short but not in those with the longest life expectancy., Competing Interests: Conflict of interest: None declared., (© The Author(s) 2022. Published by Oxford University Press on behalf of the European Society of Cardiology. All rights reserved. For permissions, please email: journals.permissions@oup.com.)

Bioprosthetic valve use has increased significantly. Considering their limited durability, there will remain an ongoing clinical need for repairing or replacing these prostheses in the future. The current standard of care for treating bioprosthetic valve degeneration involves redo open-heart surgery. However, repeat cardiac surgery may be associated with significant morbidity and mortality. With the rapid evolution of transcatheter heart valve therapies, the feasibility and safety of implanting a transcatheter heart valve within a failed tissue valve has been established. We review the historical perspective of transcatheter valve-in-valve therapy, as well as the main procedural challenges and clinical outcomes associated with this new less invasive treatment option. [ABSTRACT FROM AUTHOR]

Objectives: Despite promising short- and mid-term results for durability of the Trifecta valve, contradictory reports of early structural valve deterioration (SVD) do exist. We investigated the incidence of SVD after surgical aortic valve replacement (SAVR) with the Trifecta in our single-centre experience., Methods: Data of 347 consecutive patients (mean age 71.6 ± 9.5 years, 63.4% male) undergoing SAVR with the Trifecta between 2011 and 2017 were analysed. Clinical and echocardiographic reports were obtained with a median follow-up of 41 months (1114 patient years)., Results: Isolated SAVR was performed in 122 patients (35.2%), whereas 225 patients (64.8%) underwent concomitant procedures. The median EuroSCORE II was 4.0 (0.9; 7.1) and 30-day mortality was 3.7% (n = 13). Kaplan-Meier estimates for the freedom of overall mortality at 1, 5 and 7 years were 88.7 ± 1.7%, 73.7 ± 2.6% and 64.7 ± 4.2%, respectively. SVD was observed in 25 patients (7.2%) with a median time to first diagnosis of 73 months. Freedom of SVD was 92.5 ± 0.9% at 5 years and 65.5 ± 7.1% at 7 years. Thirteen patients underwent reintervention for SVD (6 re-SAVR, 7 valve-in-valve), resulting in a freedom of reintervention for the SVD of 98.5 ± 1.1% at 5 years and 76.9 ± 6.9% at 7 years., Conclusions: We herein report one of the highest rates of SVD after SAVR with the Trifecta. These data indicate that the durability of the prosthesis decreases at intermediate to long-term follow-up, leading to considerable rates of reintervention due to SVD., (© The Author(s) 2020. Published by Oxford University Press on behalf of the European Association for Cardio-Thoracic Surgery. All rights reserved.)