Transapical off-pump valve-in-valve implantation in patients with degenerated aortic xenografts

Background: The reoperative risk for degenerated aortic valve xenografts may be increased in elderly patients with comorbidities. We evaluated the off-pump beating heart concept of transapical aortic valve implantation using the valve-in-valve (VinV) concept.

Methods: Since March 2007, 11 patients with degenerated xenografts received transapical aortic valve implantation using the Edwards Sapien transcatheter heart valve (Edwards Lifesciences, Irvine, CA). After informed consent, all procedures were performed as an off-label use. Mean patient age was 78 +/- 6 years (range, 72 to 89), mean logistic European System for Cardiac Operative Risk Evaluation was 32% +/- 16% (range, 16% to 62%) and mean Society for Thoracic Surgeons score was 7% +/- 3% (range, 3% to 10%).

Results: All patients were treated off pump. The transapical aortic valve implantation was successful in all patients, and apical access was uncomplicated in all of them. Total operating room time was 71 +/- 14 minutes. On postoperative echocardiography, there was no paravalvular incompetence in any and mild (first degree) central incompetence in 2 of 11 patients. Sufficient flaring of the inflow and outflow parts of the Sapien prosthesis was observed in all patients, suggesting a stable position and an almost absent risk of late embolization. Maximal transvalvular pressure gradients were 21 +/- 8 mm Hg, and mean echocardiographic pressure gradients were 11 +/- 4 mm Hg. Follow-up extends to 330 +/- 293 days (range, 15 to 1,007), and all patients are well and alive.

Conclusions: Valve-in-valve implantation is a truly minimally invasive procedure for redo treatment of failed aortic valve xenografts in high-risk elderly patients. The Edwards Sapien valve is well suited for VinV implantation, and this technique may become a routine procedure to treat degenerated xenografts in the future.