Valve-in-valve TAVI for aortic bioprosthetic valve dysfunction

Evidence-based recommendations on valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) for aortic bioprosthetic valve dysfunction in adults. This involves placing a new bioprosthetic valve inside a failing bioprosthetic valve.

# Recommendations
Current evidence on the safety and efficacy of valve-in-valve transcatheter aortic valve implantation (ViVTAVI) for aortic bioprosthetic dysfunction is adequate to support the use of this procedure provided that standard arrangements are in place for clinical governance, consent and audit. Find out what standard arrangements mean on the NICE interventional procedures guidance page.
Details of all patients should be entered into the UK TAVI registry.
Device-related adverse events should be reported to the Medicines and Healthcare products Regulatory Agency.
Patient selection should be done by a multidisciplinary team, which must include interventional cardiologists experienced in the procedure, cardiac surgeons, an expert in cardiac imaging and, when appropriate, a cardiac anaesthetist and a specialist in elderly medicine. The multidisciplinary team should determine the risk level for each patient and the device most suitable for them.
During the consent process, patients should be told about all treatment options, and their advantages and disadvantages.
ViVTAVI is a technically challenging procedure that should only be done in specialised centres, and only by clinicians and teams with special training and experience in complex endovascular interventions. Units doing this procedure should have both cardiac and vascular surgical support for the emergency treatment of complications and subsequent patient care.# The condition, current treatments and procedure

# The condition
The 2 main indications for aortic valve replacement are aortic stenosis and aortic regurgitation. Symptoms of both conditions typically include shortness of breath and chest pain on exertion. The increased cardiac workload can lead to heart failure.

# Current treatments
Aortic valve replacement with an artificial prosthesis (biological or mechanical) is the conventional treatment for patients with severe aortic valve dysfunction. Valves may be placed by either open heart surgery or using transcatheter aortic valve implantation (TAVI; see NICE's interventional procedures guidance on TAVI). Although bioprosthetic valves have some advantages over mechanical valves, they may degenerate and fail over time. The standard treatment for a failed bioprosthetic valve is open heart surgery, with a further valve replacement. Reoperative surgery is associated with significant morbidity and a higher risk of mortality than primary surgery.
Valve-in-valve (ViV) TAVI has been developed as a less invasive alternative treatment that avoids the need for cardiopulmonary bypass. It can be used for treating failed bioprosthetic aortic valves originally placed by either open heart surgery or TAVI.

# The procedure
The procedure is done with the patient under general or local anaesthesia with sedation, using fluoroscopy. Prophylactic antibiotics and anticoagulant medication are used.
A new prosthetic valve is mounted within a stent, which is either self-expanding or expanded using balloon inflation. It is delivered by a catheter across the failed bioprosthetic aortic valve. Access to the aortic valve can be achieved transluminally, with entry to the circulation through the femoral or other large artery (sometimes known as a percutaneous or endovascular approach), or through apical puncture of the left ventricle (a transapical or transventricular approach). In the transluminal approach, surgical exposure and closure of the artery may be needed. How access to the aortic valve is achieved depends on whether there are factors that make the passage of a catheter through the circulation difficult, such as peripheral arterial disease.
The procedure is technically similar to TAVI for aortic stenosis into a native aortic valve, but some modifications to the technique have been reported. The new prosthetic valve is placed tightly into the orifice of the failed bioprosthetic valve, pushing the old valve leaflets aside. Gradual valve deployment (without rapid inflation of the balloon) is done and angiography is used to ensure accurate positioning of the valve. The old prosthesis is also used as a guide for positioning the new valve. The external diameter of the new valve should usually match or exceed the internal diameter of the old valve. Anticoagulation or antiplatelet therapy may be continued after the procedure.