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Original research article
Incidence, predictors and clinical outcomes of residual stenosis after aortic valve-in-valve
  1. Sabine Bleiziffer1,2,
  2. Magdalena Erlebach1,2,
  3. Matheus Simonato3,4,
  4. Philippe Pibarot5,
  5. John Webb4,
  6. Lukas Capek6,
  7. Stephan Windecker6,
  8. Isaac George7,
  9. Jan-Malte Sinning8,
  10. Eric Horlick9,
  11. Massimo Napodano10,
  12. David M Holzhey11,
  13. Petur Petursson12,
  14. Alfredo Cerillo13,
  15. Nikolaos Bonaros14,
  16. Enrico Ferrari15,
  17. Mauricio G Cohen16,
  18. Giselle Baquero16,17,
  19. Tara L Jones18,
  20. Ankur Kalra19,20,
  21. Michael J Reardon21,
  22. Adnan Chhatriwalla22,
  23. Vasco Gama Ribeiro23,
  24. Sami Alnasser9,
  25. Nicolas M Van Mieghem24,
  26. Christian Jörg Rustenbach25,
  27. Joachim Schofer26,
  28. Santiago Garcia27,
  29. Tobias Zeus28,
  30. Didier Champagnac29,
  31. Raffi Bekeredjian30,
  32. Ran Kornowski31,
  33. Rüdiger Lange1,2,
  34. Danny Dvir4,18
  1. 1 Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
  2. 2 Insure (Institute for Translational Cardiac Surgery), Department of Cardiovascular Surgery, German Heart Center Munich, Technische Universität München, Munich, Germany
  3. 3 Division of Cardiovascular Surgery, Department of Surgery, Escola Paulista de Medicina - UNIFESP, São Paulo, Brazil
  4. 4 Centre for Heart Valve Innovation, St. Paul’s Hospital, Vancouver, British Columbia, Canada
  5. 5 Department of Medicine, Laval University, Institut Universitaire de Cardiologie et de Pneumologie de Québec, Quebec City, Québec, Canada
  6. 6 University Hospital of Bern, Bern, Switzerland
  7. 7 Columbia University, New York, USA
  8. 8 University of Bonn, Bonn, Germany
  9. 9 Peter Munk Cardiac Centre, University Health Network, Toronto, Canada
  10. 10 University of Padova, Padova, Italy
  11. 11 University of Leipzig, Leipzig, Germany
  12. 12 Sahlgrenska University Hospital, Gothenburg, Sweden
  13. 13 Fondazione Toscana Gabriele Monasterio, Pisa, Italy
  14. 14 Innsbruck Medical University, Innsbruck, Austria
  15. 15 Cardiocentro Ticino, Lugano, Switzerland
  16. 16 University of Miami, Miami, Florida, USA
  17. 17 Southern Illinois University, Springfield, Illinois, USA
  18. 18 University of Washington, Seattle, Washington, USA
  19. 19 Harrington Heart & Vascular Institute, University Hospitals Cleveland Medical Center, Cleveland, Ohio, USA
  20. 20 Division of Cardiovascular Medicine, Department of Medicine, Case Western Reserve University School of Medicine, Cleveland, Ohio, USA
  21. 21 Houston Methodist, Houston, Texas, USA
  22. 22 Saint Luke’s Mid America Heart Institute, Kansas City, Missouri, USA
  23. 23 Centro Hospitalar Vila Nova de Gaia, Vila Nova de Gaia, Portugal
  24. 24 Erasmus Medical Center, Rotterdam, The Netherlands
  25. 25 Heartcenter, Department of Cardiovascular Surgery, University Hospital Cologne, Cologne, Germany
  26. 26 Albertinen Herzzentrum, Hamburg, Germany
  27. 27 Minneapolis VA Healthcare System, University of Minnesota, Minneapolis, Minnesota, USA
  28. 28 University Hospital Duesseldorf, Duesseldorf, Germany
  29. 29 Clinique du Tonkin, Villeurbanne, France
  30. 30 University of Heidelberg, Heidelberg, Germany
  31. 31 Rabin Medical Center, Petah Tikva, Israel
  1. Correspondence to Dr Danny Dvir, University of Washington, Seattle, WA 98195-6422, USA; danny.dvir{at}


Objective We aimed to analyse the incidence of prosthesis–patient mismatch (PPM) and elevated gradients after aortic valve in valve (ViV), and to evaluate predictors and associations with clinical outcomes of this adverse event.

Methods A total of 910 aortic ViV patients were investigated. Elevated residual gradients were defined as ≥20 mm Hg. PPM was identified based on the indexed effective orifice area (EOA), measured by echocardiography, and patient body mass index (BMI). Moderate and severe PPM (cases) were defined by European Association of Cardiovascular Imaging (EACVI) criteria and compared with patients without PPM (controls).

Results Moderate or greater PPM was found in 61% of the patients, and severe in 24.6%. Elevated residual gradients were found in 27.9%. Independent risk factors for the occurrence of lower indexed EOA and therefore severe PPM were higher gradients of the failed bioprosthesis at baseline (unstandardised beta −0.023; 95% CI −0.032 to –0.014; P<0.001), a stented (vs a stentless) surgical bioprosthesis (unstandardised beta −0.11; 95% CI −0.161 to –0.071; P<0.001), higher BMI (unstandardised beta −0.01; 95% CI −0.013 to –0.007; P<0.001) and implantation of a SAPIEN/SAPIEN XT/SAPIEN 3 transcatheter device (unstandardised beta −0.064; 95% CI −0.095 to –0.032; P<0.001). Neither severe PPM nor elevated gradients had an association with VARC II-defined outcomes or 1-year survival (90.9% severe vs 91.5% moderate vs 89.3% none, P=0.44).

Conclusions Severe PPM and elevated gradients after aortic ViV are very common but were not associated with short-term survival and clinical outcomes. The long-term effect of poor post-ViV haemodynamics on clinical outcomes requires further evaluation.

  • valve disease surgery
  • transcatheter valve interventions
  • valvular heart disease
  • prosthetic heart valves

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  • Contributors SB, ME, MS, PP, RL and DD were responsible for the drafting of the manuscript. MS was responsible for the acquisition of data and statistical analysis. SB, RL and DD were responsible for the organisation and supervision of the study. JW, LC, SW, IG, J-MS, EH, MN, DMH, PP, AC, NB, EF, MGC, GB, TLJ, AK, MJR, AC, VG-R, SA, NMVM, CJR, J-MS, SG, TZ, DC, RB and RK assisted with acquisition of data and provided critical comments and revision for intellectual content. All authors approved the final version of the manuscript.

  • Competing interests DD is a consultant for Edwards Lifesciences, Medtronic and Abbott. SB is a proctor and consultant for Medtronic and a proctor for Boston Scientific and JenaValve. RL is a member of the Medtronic advisory board. SG is a consultant for Edwards Lifesciences, Medtronic, Surmodics, Osprey Medical and Boston Scientific and also repots research grants from Edwards Lifesciences and VA Office of Research and Development. EF reports consulting and proctoring for Edwards Lifesciences. DH is a member of the Medtronic advisory board. TZ reports lecture fees from Edwards Lifesciences and Medtronic. MJR is a consultant for Medtronic, Abbott and Boston Scientific. SW reports institutional research grants from Amgen, Abbott, Boston Scientific, Biotronik and St. Jude Medical. NMvM reports research grant support from Medtronic, Abbott, Edwards Lifesciences, Boston Scientific, Claret and Essential Medical. NB has received research grants from Edwards Lifesciences and speaker honoraria from Edwards Lifesciences, Medtronic and Abbott. AC is part of the speakers bureau for Edwards Lifesciences, Medtronic and Abbott, and also reports proctoring for Medtronic. J-MS reports research grants and speaker honoraria from Medtronic, Edwards Lifesciences, Boston Scientific, and Abbott. No other conflicts of interest were reported.

  • Provenance and peer review Not commissioned; externally peer reviewed.