**VALVE CASES OF THE WEEK**

Yes, you read correctly...caseS, plural! This week we discuss...the failing aortic bioprosthesis. Several cases, several polls, much to debate!

Many of you will have seen this large French study published recently...

A retrospective propensity score matched study of patients that underwent re-do sAVR or V-in-V TAVI between 2010-2019, by the look of things only for patients that had prosthesis stenosis, not bioprosthesis failure due to regurgitation (see Methods snapshot below)

Anyway, accompanying editorial was v. interesting. Specifically, see highlighted sentence below.

It is true that V-in-V TAVI has become a 'common sense' solution for many patients before RCT has confirmed this...are we too late? Could we do an RCT now? I think Yes. Here's why...

Case 1: pt in early 90s, had 21mm tissue AVR in mid 80s, re-presents in acute HF with severe AR. Frail, surgeons & pt not keen on re-do AVR. V-in-V app suggests 20mm TAVI valve would be needed. Here is PLAX view on echo...

Poll - what do you think is *probably* (given limited info you have) best option here?

We'll see what everyone votes for...but pt had a V-in-V TAVI. Procedure went well.

Post-op TTE - Vmax 3.4m/s, mean AVG 31mmHg.

So, pt has traded severe AR for moderate AS. Not ideal...but, 1yr later, pt is still alive & doing OK. So overall I'd suggest a good outcome

Case 2 - pt in mid 80s, had 23mm tAVR 8yrs prior, again presented acutely in severe HF. Weight <50kg, mildly frail. TTE below...AR was trans, not paravalvular. V-in-V app indicates 23mm TAVI valve would be appropriate.

Again, poll on next slide...

Poll - what do you think is *probably* best option for the patient here?

Again, I suspect most of you will vote for TAVI in someone in their mid 80s...which is what patient had. This patient's post-procedure TTE is below with good outcome.

What about next case though...

Pt in early 60s. Physically fit & well. 25mm tissue AVR ~15yrs ago for AR. Now has severe transvalvular AR. Pt adamant they don't want sternotomy now, wants V-in-V TAVI this time & accepts may need 3rd procedure later in life.

Here is a modified TOE AV 120 degrees view

Treadmill test - finished 12mins Bruce protocol, no symptoms. Rest & peak stress ECGs below. LV images post stress showed cavity dilatation & slight fall in EF...so discussed at length at MDT meeting. V-in-V app suggests 26mm TAVI valve would be suitable if performed.

Poll - what do you think is best option here, given limited clinical info you have?

You may not agree, but in the end pt had V-in-V TAVI. Patient choice. Successful procedure.

Here is pre-discharge TTE:

6 months later patient feels fine, active and asymptomatic. But has AV Vmax 3.6-3.7m/s...in early 60s. How long will this last? Only time will tell!

So, coming back to the Q of RCT, yes I believe we DO need an RCT but, ideally, we need MORE than one. The 85yr old and 60yr old with failing biological valves are very different scenarios and ideally would not be in the same trial.

I don't know if we could run a trial of V-in-V TAVI versus re-do sAVR in the very elderly (definitely >85yrs, possibly >80) as, even if you got ethical approval, not sure clinicians would put their patients forward for randomization. We saw that in the STICH trial, for example...

For me, the REAL unanswered Q is in the 60-75yrs old cohort - with the massive in biological valves implantated since 2000, we're going to see a lot more failures in patients in their 60s & 70s...we DO need an RCT in that group, we really do!

I worry that patients in their 50s deliberately choose a biological valve on the assumption in 10yrs time they can have a TAVI and it'll be fine...in time that *may* prove a reasonable strategy but we have ZERO long term data to support that strategy right now

We know that patient prosthesis mismatch is a real issue in V-in-V TAVI and it's not only seen in patients that originally had 19mm or 21mm valves; we do see it sometimes in the 23mm & even 25mm sAVR patients too.

My thoughts:
- Failing tAVR is big issue & we're going to see cases
- V-in-V TAVI is brilliant bailout for patients unfit/high risk for re-do AVR
-May not be able to perform RCT in high surgical risk pts
-MUST perform properly designed RCT in low/intermediate surgical risk pts

@psmedic @TharushaGunawa4 @reemhas88138365 @ovidiogarciav @drjodarcy

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