By Dr. Girish B Navasundi Posted on January 16, 2025

Valve-in-Valve Procedures: A Case Study on Minimally Invasive TAVI

The field of cardiology continues to evolve, with groundbreaking innovations paving the way for improved treatment outcomes and patient care. Among these advancements, Transcatheter Aortic Valve Implantation (TAVI) has emerged as a transformative approach to treating patients with aortic valve conditions. Recently, we had the privilege of working on a complex valve-in-valve (ViV) case, which showcased the power of modern cardiology in addressing challenges once deemed insurmountable.

This blog delves into the details of the case, explores the significance of the TAVI procedure, and highlights its impact on patient outcomes.

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Understanding the Patient’s Condition

The patient presented with a previously implanted 21mm Biocar Epic Supra surgical valve, which had begun to deteriorate over time, causing symptoms and complications that required immediate intervention. Degeneration of surgically implanted valves is not uncommon, particularly as patients live longer post-surgery. Traditional surgical replacement would typically involve open-heart surgery—a procedure associated with significant risks, longer recovery times, and higher complication rates, particularly in high-risk patients.

Valve-in-valve TAVI has emerged as a minimally invasive alternative to surgical reoperation. This innovative procedure offers a safer and less invasive solution, reducing the physical burden on patients while ensuring effective valve replacement.

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The Case Details: Collaborative Expertise in Action

Pre-Procedure Assessment

A comprehensive evaluation of the patient was conducted, which included:

• Imaging tests, such as CT angiography, to assess the existing valve’s structure and its interaction with surrounding anatomy.
• Echocardiography to measure valve performance and detect complications like stenosis or regurgitation.
• Risk assessments to determine the patient’s eligibility for TAVI and potential procedural challenges.

The analysis revealed that the patient’s 21mm Biocar Epic Supra valve required precise replacement due to its small size and the anatomical constraints it presented. This required meticulous planning to ensure the new valve would fit seamlessly and restore optimal function.

The Procedure

Working alongside Dr. Mehul Patel, our team performed the TAVI procedure using a 23mm Evolut FX valve. Key highlights of the procedure included:

1. Minimally Invasive Access: Using the transfemoral approach, the Evolut FX valve was delivered to the heart through a catheter inserted in the femoral artery.
2. Precision Deployment: Advanced imaging and navigation systems were used to position the new valve within the existing Biocar Epic Supra valve with millimeter-level accuracy.
3. Valve Expansion: The self-expanding design of the Evolut FX allowed it to adapt to the constraints of the smaller surgical valve, ensuring a secure fit and restoring proper blood flow.

Post-Procedure Outcomes

The procedure was a success, with immediate improvement in the patient’s valve function and hemodynamics. The minimally invasive nature of TAVI allowed for:

• Reduced procedural risks.
• Shorter hospital stays.
• Faster recovery and improved quality of life.

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Why TAVI is a Game-Changer

TAVI is redefining the standard of care for patients with severe aortic stenosis and failing bioprosthetic valves. Its minimally invasive nature is particularly beneficial for high-risk or elderly patients who may not tolerate traditional surgery well.

Advantages of TAVI

1. Minimally Invasive: No need for open-heart surgery, leading to smaller incisions and reduced pain.
2. Shorter Recovery Time: Patients typically return to normal activities within days to weeks, compared to months after traditional surgery.
3. Improved Safety: Lower risk of complications, such as infections or prolonged hospital stays.
4. Precise Valve Placement: Advanced imaging technology ensures optimal outcomes, even in challenging anatomies.

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The Evolut FX Valve: Precision Redefined

The Evolut FX valve used in this case is a state-of-the-art self-expanding valve that offers unique advantages:

• Enhanced Conformability: Designed to adapt to varying anatomies, including smaller surgical valves.
• Advanced Imaging Markers: Improves visibility during the procedure, aiding precise placement.
• Durability: Offers long-term performance, ensuring the valve remains functional for years.

In this case, the Evolut FX valve proved to be the ideal choice, overcoming the constraints of the 21mm Biocar Epic Supra valve and delivering excellent results.

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Challenges in Valve-in-Valve TAVI Procedures

Valve-in-valve procedures are inherently more complex than primary TAVI due to factors like:

• Limited Space: Small surgical valves pose challenges for deploying new valves.
• Anatomical Variations: Pre-existing surgical modifications may affect positioning and anchoring.
• Imaging Limitations: Ensuring accurate placement within the existing valve requires advanced imaging techniques and expertise.

Despite these challenges, advancements in technology and surgical techniques, combined with collaborative expertise, continue to drive success rates higher.

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Looking Ahead: The Future of TAVI

The case underscores the growing potential of TAVI in addressing complex cardiovascular conditions. As technology continues to advance, we can expect:

• Expanded Indications: TAVI may soon become a first-line treatment for younger and lower-risk patients.
• Improved Valve Designs: Innovations in valve technology will address anatomical challenges and enhance durability.
• Personalized Treatment: Tailored approaches to suit each patient’s unique anatomy and medical history.

FAQs About Valve-in-Valve TAVI

1. What is a valve-in-valve procedure?

A valve-in-valve procedure involves implanting a new valve within a failing surgical or bioprosthetic valve. It is a minimally invasive alternative to surgical reoperation.

2. How does TAVI differ from traditional valve replacement surgery?

TAVI is a minimally invasive procedure performed through a catheter, while traditional surgery requires open-heart surgery. TAVI offers shorter recovery times and reduced risks.

3. Who is eligible for valve-in-valve TAVI?

Patients with failing surgical valves and those at high risk for traditional surgery are typically considered for valve-in-valve TAVI. A detailed evaluation determines eligibility.

4. What are the risks associated with valve-in-valve TAVI?

While TAVI is generally safe, risks include bleeding, stroke, valve misplacement, or complications related to the catheter insertion site.

5. What is the lifespan of a TAVI valve?

Modern TAVI valves, like the Evolut FX, are designed to last 10-15 years or more, depending on patient-specific factors.

6. How soon can patients resume normal activities after TAVI?

Most patients can resume normal activities within a few days to weeks, depending on their recovery progress and overall health.

7. Is TAVI covered by insurance?

In most cases, TAVI is covered by insurance for eligible patients. However, coverage details vary, and it’s advisable to consult with your provider.

8. Can TAVI be repeated if the replacement valve fails?

Yes, a repeat TAVI procedure or alternative treatments may be possible if the replacement valve fails. A detailed evaluation will guide the next steps.

Dr. Girish B Navasundi

Senior Consultant Interventional Cardiologist & Certified TAVR Specialist, Lead Consultant – Structural Heart Disease & Heart Failure

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