Failed Surgical Heart Valve ? Consider Valve-in-Valve TAVI / TMVR

"Valve in Valve" refers to a specific application of TAVI where a new valve is implanted within a previously implanted bioprosthetic valve. This approach is used when a patient has a failing bioprosthetic valve but is at high risk for another open-heart surgery. By using TAVI for valve-in-valve procedures, it is possible to replace a worn-out bioprosthetic valve without performing a full surgical intervention.

Redo Surgery Vs Valve-in-Valve TAVI/ TAVR:

The decision between redo surgery and valve-in-valve TAVI depends on several factors and should be made on a case-by-case basis. The choice of treatment depends on the patient's overall health, the condition of the previous valve, the anatomy of the aortic valve, and the expertise and experience of the medical team.

Here are some considerations for each option:

Redo Surgery:

• Durability: Surgical mechanical valve replacement typically offers better long-term durability compared to bioprosthetic valves used in TAVI. If a patient is young or has a longer life expectancy, redo surgery may be preferred to ensure a longer-lasting valve replacement.

• Surgical Risk: Redo surgery is an invasive procedure that requires open-heart surgery. It may carry higher risks, especially in patients who are elderly, have multiple comorbidities, or are considered high-risk for surgical complications.

• Anatomical Considerations: The anatomy of the aortic valve and the surrounding structures play a role in determining the suitability for redo surgery. Some patients may have anatomical features that make redo surgery more challenging or risky.

Valve-in-Valve TAVI:

• Minimally Invasive: Valve-in-valve TAVI is a minimally invasive procedure, which generally leads to shorter recovery times, reduced hospital stays, and fewer post-operative complications compared to redo surgery.

• Surgical Risk: For patients who are considered high-risk or ineligible for redo surgery due to underlying health conditions, valve-in-valve TAVI can provide a less invasive alternative with lower surgical risks.

• Age and Life Expectancy: Valve-in-valve TAVI may be preferred for older patients or those with shorter life expectancy, where the focus is on symptom relief and improving quality of life rather than long-term durability.

Ultimately, the decision should be made after a thorough evaluation by a multidisciplinary heart team, including cardiac surgeons and interventional cardiologists, who can assess the individual patient's situation and determine the most suitable treatment approach. The team will consider factors such as the patient's age, overall health, valve characteristics, and the risks and benefits associated with each option to provide personalized recommendations.

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Risks in Valve-in Valve TAVI:

Valve-in-valve TAVI, like any medical procedure, carries certain risks. While it is generally considered a safe and effective treatment option, it's important to be aware of potential complications. Here are some of the risks associated with valve-in-valve TAVI:

1. Procedural risks: such as bleeding, infection, blood vessel damage, or allergic reactions to anesthesia or contrast agents. These risks are similar to those associated with the standard TAVI procedure.

2. Device-related risks: The implanted valve may have complications, including valve malposition, paravalvular leak (leakage around the valve), valve migration, or valve embolization (dislodgement of the valve). These issues can affect the valve's performance and may require additional interventions or surgeries.

3. Structural deterioration: Over time, bioprosthetic valves can degenerate and fail, regardless of whether they were implanted through surgery or TAVI. The durability of the valve-in-valve procedure depends on the condition and longevity of the original bioprosthetic valve.

4. Coronary artery obstruction: In rare cases, the placement of a new valve within the existing valve can obstruct the coronary arteries, which supply blood to the heart muscle. In which case, emergency coronary stenting would be required

5. Other complications: Other potential risks include stroke, damage to the electrical conduction system of the heart, kidney injury, or vascular complications, such as bleeding or dissection (tearing) of blood vessels.

It's important to note that the specific risks and their likelihood can vary depending on factors such as the patient's overall health, anatomy, and the skill and experience of the medical team performing the procedure. Before undergoing any medical intervention, it is crucial to have a detailed discussion with your healthcare provider, who can provide personalized information about the risks and benefits based on your specific circumstances.

MRI safety of TAVR or TAVI Valves

Transcatheter Aortic Valve Implantation (TAVI) is a minimally invasive procedure used to replace a diseased aortic valve with a prosthetic valve. Magnetic Resonance Imaging (MRI) is a diagnostic imaging technique that uses a strong magnetic field and radio waves to generate detailed images of the body's internal structures. When considering the safety of TAVI in relation to MRI, there are a few important points to consider:

1. MRI Compatibility of TAVI Devices: The prosthetic valves used in TAVI procedures are typically made of metal and may contain components that can be affected by the strong magnetic field of an MRI machine. In the past, many TAVI devices were considered contraindicated for MRI due to potential risks such as valve displacement or heating. However, newer generations of TAVI devices have been developed with improved MRI compatibility.

You can check the MRI compatibility of your valve or device at : http://www.mrisafety.com/TMDL_list.php

2. MRI Conditional TAVI Devices: Some TAVI devices are specifically designed and labeled as "MRI conditional." This means that they have been tested and determined to be safe for use in patients undergoing MRI under certain conditions. The manufacturer's instructions for use (IFU) provide specific information regarding the MRI conditions that can be safely followed, such as the maximum magnetic field strength, specific absorption rate (SAR) limits, and scanning sequences.

3. Precautions and Assessments: Before undergoing an MRI, it is essential to assess the specific TAVI device implanted and its compatibility with MRI. This assessment is typically performed by the treating physician or a radiologist. They will review the patient's medical history, including the details of the TAVI procedure and the implanted device, and consult the device manufacturer's guidelines to determine if an MRI can be safely performed.

4. Monitoring and Follow-up: In some cases, additional monitoring may be required during an MRI scan for patients with TAVI devices. This may involve continuous monitoring of vital signs and electrocardiography (ECG) to ensure the patient's safety throughout the procedure. The medical team will closely observe the patient for any signs of discomfort, abnormal valve function, or complications during and after the MRI.

It's important to note that the specific safety guidelines and recommendations can vary depending on the TAVI device used and its MRI compatibility. Therefore, it is crucial for patients and healthcare professionals to consult the device manufacturer's instructions and work together to make informed decisions regarding MRI safety for individuals with TAVI implants.

TAVR Valve durability or Lifespan of TAVI Valve

The durability of TAVR (Transcatheter Aortic Valve Replacement) valves is an important consideration when deciding on treatment options for patients with aortic stenosis. While TAVR has been shown to be a safe and effective alternative to open-heart surgery for many patients, the long-term durability of the TAVR valve is still being studied.

Several studies have reported on the durability of TAVR valves over time, with results suggesting that TAVR valves may have similar or better durability compared to surgical valves in selected patients. For example, a study published in the New England Journal of Medicine in 2021 reported that among patients at intermediate surgical risk, the rate of structural valve deterioration at 5 years was similar between TAVR and SAVR (Surgical Aortic Valve Replacement) patients. Another study published in the Journal of the American College of Cardiology in 2020 reported that among high-risk patients, TAVR valves had similar or better durability compared to surgical valves up to 5 years.

However, it is important to note that the long-term durability of TAVR valves is still being studied and longer-term data are needed to fully understand the durability of these valves. Additionally, the durability of TAVR valves may vary depending on factors such as the patient's age, comorbidities, and the type of valve used.

In summary, while the long-term durability of TAVR valves is still being studied, current evidence suggests that TAVR valves may have similar or better durability compared to surgical valves in selected patients, particularly among those at high risk for surgery. Patients should discuss the potential benefits and risks of TAVR with their doctors to determine if it is the best treatment option for their individual case.

In real world experience, Edwards sapien and Medtronic Corevalve are being in use for long time since the time of TAVI evolution (>20 years) and good number of people have had functioning valve beyond 10-12 years - more so with balloon expandable valve.