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    Transcatheter Aortic Valve-In-Stentless Surgical Aortic Valve Insertion: Hype or Hope?

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    Transcatheter Aortic Valve-In-Stentless Surgical Aortic Valve Insertion: Hype or Hope?

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    Transcatheter Aortic Valve-In-Stentless Surgical Aortic Valve Insertion: Hype or Hope?

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    of 2

    EDITORIAL COMMENTARY

    Transcatheter aortic valve–in–stentless surgical aortic valve


    insertion: Hype or hope?
    Kevin L. Greason, MD

    of isolated severe aortic valve regur-


    See related article on pages 91-8. gitation. The struggle is twofold: (1)
    identifying the correct anatomic po-
    sition to deploy the valve and (2)
    Readers of the Journal will find interest in this issue’s avoiding valve migration, because
    article by Duncan and colleagues1 about transcatheter aortic there is no stenosis in which to an-
    valve-in-valve insertion for failing surgical aortic stentless chor the transcatheter prosthesis.
    bioprosthetic valves. There is no shortage of ballyhoo pro- Duncan and colleagues1 report
    moting initial biologic surgical aortic valve replacement that during valve insertion fluoro-
    with planned transcatheter aortic valve-in-valve insertion scopic images were obtained coax-
    bailout for subsequent surgical valve deterioration. Is that ial to the stentless aortic valve prosthesis in 19 patients
    hype, or is it a hoped for effective treatment algorithm? with valvular calcification. There was no calcification,
    The study in this issue applies some welcome scientific however, in 3 patients (14%). In that group, the authors
    investigation to the issue. placed catheters in the noncoronary and left coronary
    This report is important for 3 reasons: (1) it concentrates sinuses to aid delineation of the target landing zone,
    on the specific issue of valve–in–stentless surgical aortic and this is a helpful technical note. The final position
    valve insertion; (2) it highlights the difficulty of transcath- of the transcatheter device was confirmed by transesopha-
    eter valve insertion in the setting of severe aortic valve geal echocardiography before the device was fully
    regurgitation; and (3) it reports on the detailed use of the deployed.
    CoreValve transcatheter valve (Medtronic plc, Minneapo- Duncan and colleagues1 report excellent outcomes. The
    lis, Minn). coronary artery occlusion rate and 30-day mortality were
    The focus of this study is 22 high-risk patients (Society of both notably 0%. The mean transcatheter aortic valve sys-
    Thoracic Surgeons predicted mortality risk of 14%  8%) tolic Doppler gradient was only 12  9 mm Hg, and para-
    with failing stentless surgical aortic valve prostheses: ho- valvular regurgitation was none to mild in 19 patients and
    mograft in 17 patients, Toronto valve (St Jude Medical, mild to moderate in 3, with no occurrences of severe regur-
    Inc, St Paul, Minn) in 3, Freestyle valve (Medtronic) in 1, gitation. These levels of regurgitation were unchanged at 1-
    and native resuspended aortic valve in 1. The mode of valve year follow-up, and there were no instances of late valve
    failure was severe aortic valve regurgitation, without any migration.
    mention of valve stenosis. There were, however, 3 cases of acute device migration
    Duncan and colleagues1 used multislice computed to- and 1 of device embolization. Overall procedure success
    mography to determine the aortic valve annulus size. Mea- was defined as a single valve implanted in the correct
    surements were standard for any transcatheter aortic valve anatomic location, and this was achieved in only 18 patients
    insertion assessment and included height of the coronary (82%). The device embolization was technically related,
    arteries, aortic annulus perimeter, and left ventricular but why the otherwise relatively low implantation success
    outflow tract in orthogonal planes. Duncan and col- rate?
    leagues1 based their transcatheter valve selection on the The answer may relate to inadequate transcatheter valve
    annular perimeter. oversizing. Duncan and colleagues1 report that the median
    Surgeons and cardiologists who perform transcatheter perimeter valve oversizing in this group of patients was
    aortic valve insertion will recognize the perceived difficulty only 4.7% (range 4.9% to 24.3%). Current experience
    with valve–in–stentless aortic valve insertion in the setting with the CoreValve prosthesis, as reported by Dvir and col-
    leagues,2 is that greater oversizing (ie, >15%) is probably
    From the Division of Cardiovascular Surgery, Mayo Clinic, Rochester, Minn. indicated.
    Disclosures: Author has nothing to disclose with regard to commercial support. In this single-center series of high-risk patients, out-
    Received for publication March 28, 2015; accepted for publication March 30, 2015; comes were excellent with respect to morbidity and mortal-
    available ahead of print May 1, 2015.
    Address for reprints: Kevin L. Greason, MD, Division of Cardiovascular Surgery, ity. It is likely that greater transcatheter valve oversizing
    Mayo Clinic, Rochester, MN 55905 (E-mail: greason.kevin@mayo.edu). will result in less paravalvular regurgitation and acute valve
    J Thorac Cardiovasc Surg 2015;150:99-100 migration. The preliminary assessment is that transcatheter
    0022-5223/$36.00
    Copyright Ó 2015 by The American Association for Thoracic Surgery aortic valve–in–stentless surgical aortic valve insertion is
    http://dx.doi.org/10.1016/j.jtcvs.2015.03.060 not hype, but it is to be hoped a useful paradigm.

    The Journal of Thoracic and Cardiovascular Surgery c Volume 150, Number 1 99


    Editorial Commentary Greason

    References 2. Dvir D, Webb JG, Piazza N, Blanke P, Barbanti M, Bleiziffer S, et al.


    1. Duncan A, Davies S, Di Mario C, Moat N. Valve-in-valve transcatheter aortic Multicenter evaluation of transcatheter aortic valve replacement using either
    valve implantation for failing surgical aortic stentless bioprosthetic valves: A SAPIEN XT or CoreValve: degree of device oversizing by computed-tomography
    single-center experience. J Thorac Cardiovasc Surg. 2015;150:91-8. and clinical outcomes. Catheter Cardiovasc Interv. April 2, 2015 [Epub ahead of print].

    100 The Journal of Thoracic and Cardiovascular Surgery c July 2015

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