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Valvular heart diseases
Transcatheter heart valve implantation for failing surgical bioprostheses: technical considerations and evidence for valve-in-valve procedures
  1. Dagrren Mylotte1,
  2. Ruediger Lange2,
  3. Giuseppe Martucci1,
  4. Nicolo Piazza1,2
  1. 1Department of Interventional Cardiology, McGill University Health Centre, Montreal, Quebec, Canada
  2. 2Department of Cardiovascular Surgery, German Heart Centre, Munich, Germany
  1. Correspondence to Dr Nicolo Piazza, Department of Interventional Cardiology, McGill University Health Centre, Montreal, Quebec 80636, Canada; nicolopiazza{at}

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Transcatheter aortic valve implantation (TAVI) represents a novel technology for treating patients with severe symptomatic calcific aortic stenosis at high or prohibitive surgical risk. In patients at excessive surgical risk, TAVI substantially reduces mortality compared to medical treatment,1 and in high risk cohorts provides similar safety and efficacy to surgical aortic valve (SAV) replacement.2

More recently, the remit of transcatheter heart valve (THV) technology has been expanded beyond that initially conceived: patients at lower surgical risk are being treated despite a lack of evidence in this patient populationw1; and novel implantation techniques, such as the transaortic approach, have been developed.w2 Perhaps the most notable adaptation of this technology is the treatment of patients with failing surgical bioprosthetic valves. In 2007, Wenaweser and colleagues reported the implantation of a Medtronic CoreValve (Medtronic CV, Luxembourg S.a.r.l.) into a degenerated surgical aortic bioprosthesis.3 Since this first case, numerous transcatheter aortic valve in surgical aortic valve (TAV-in-SAV) procedures have been performed,4–7 w3–11 and experienced physicians are adapting current THVs for treatment of failing surgical atrioventricular8 w12 and pulmonary bioprostheses.9

Design characteristics of surgical bioprostheses

Successful valve-in-valve (VIV) procedures are dependent on a thorough understanding of the design characteristics and failure modes of surgical bioprosthetic valves. Surgical bioprostheses are constructed as either stented or stentless valves (figure 1), while the valve leaflets are of xenograft (porcine aortic valve or bovine pericardium) or homograft origin.10

Figure 1

Stented and stentless bioprosthetic surgical valves. (A) Stented pericardial bovine bioprosthetic valves. (B) Stented porcine aortic valve bioprostheses. (C) Stentless bioprosthetic valves.

Stented valves

Stented valves usually consist of a base ring covered by a fabric sewing cuff from which a stent or frame arises to support the valve leaflets (figure 2). The base ring may be circular or scalloped and is constructed from a variety of metal …

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  • Darren Mylotte is supported by the Beth Raby Fellowship Program.

  • Contributors All authors have contributed significantly to the submitted work.

  • Competing interests In compliance with EBAC/EACCME guidelines, all authors participating in Education in Heart have disclosed potential conflicts of interest that might cause a bias in the article. Dr Piazza is a consultant for Medtronic. Professor Lange is a consultant for Medtronic.

  • Provenance and peer review Commissioned; internally peer reviewed.