Digital Theses Archive


Tesi etd-10042019-105018

Type of thesis
Master univ. II liv.
E-mail address
Double trouble: transapical valve in valve therapy in high risk patient
Percutaneous interventional treatment of structural heart diseases
relatore Prof.ssa PETRONIO, ANNA SONIA
Membro Prof. BERTI, SERGIO
Presidente Prof. PASSINO, CLAUDIO
  • high risk
  • TMVR
  • transapical
Exam session start date
Transcatheter valve therapies have revolutionized the way in which structural heart disease is treated in patient populations ineligible for operation or with high surgical risk. <br>Nearly 80 000 aortic valve replacements (AVRs) have been performed annually in the United States in an increasingly older and sicker patient population. In the last decade, there is a trend for the patients undergoing for the first time to surgical valvular substitution to choose bioprosthetic valves over mechanical valves and hence during their lifetime, a large number of these patients will require reoperation. Bioprostheses are an attractive alternative to the more thrombogenic mechanical prostheses because they were associated with a lower risk of stroke and hemorrhage.<br>The risks of a redo procedure are usually higher for the risk of degeneration of the valve structure or after endocarditis. Further, age and comorbidities may preclude many patients from such an operation. <br>As an alternative, valve-in-valve (VIV) can be performed in a minimally invasive fashion without the need for cardio-pulmonary bypass within the degenerated surgical heart valves (SHV) and has emerged as an attractive option for these patients. Medtronic and Edwards valves received FDA approval in 2015 and 2017. A metanalysis of six observational studies and 594 patients described no significant differences netween ViV-TAVI and redo-SAVR for procedural, 30 day and 1 year mortality rates. <br>Unlike TAVR, the experience with transcatheter mitral valve replacement (TMVR) remains at an early stage because of valves developement and possible complications (valve displacements and left ventricular outlet tract obstruction). In high risk patients with severe aortic stenosis and mitral valve disease, concomitant surgery of both valves may have similar long term suvival as described for TAVR alone (Mortality rate was 25% at 6 months and 45% at 2 years). One-third of the patients with severe symptomatic aortic valve stenosis (sAS) present with hemodynamic relevant mitral valve insufficiency (rMI). In patients who undergo conventional surgery, the rMI never would be left untreated; however, in cases of transcatheter aortic valve implantation (TAVI), the impact of rMI is often overlooked and left untreated.<br>Surgical mitral valve repair or replacement remains the gold standard<br>for treating severe symptomatic mitral valve disease. Up to 35% of<br>patients require a repeat operation during the first 10 years, and the inhospital mortality rate may be as high as 12%.1,2 Furthermore, some<br>patients requiring mitral valve repair/replacement are deemed to be<br>too high risk for repeat surgery. Transcatheter mitral valve-in-valve (TMVIV) and valve-in-ring (TMVIR) implantation for degenerated mitral bioprostheses and failed annuloplasty rings have recently emerged as treatment options for patients deemed unsuitable for repeat surgery. The use of Edwards Sapien 3 is expanded by US FDA also for bioprosthetic mitral valve.<br>