Feasibility of Valve in Valve After Transcatheter Aortic Valve Replacement With SAPIEN 3 Valves and Surgical Aortic Valve Replacement

Background: The feasibility of transcatheter intervention after transcatheter aortic valve replacement (TAVR) and surgical aortic valve replacement (SAVR) is important for the lifetime management of aortic stenosis. Methods: A multicenter study was conducted of 4 patient groups: (1) TAVR using SAPIEN 3 at ≤90% implant depth, (2) TAVR using SAPIEN 3 at >90% implant depth, (3) SAVR, and (4) SAVR with aortic root enlargement (ARE) who underwent post-treatment computed tomography. Future TAVR was classified as challenging if the simulated neo-skirt was at or above the coronary ostia and <4 mm away from the coronary ostia and/or <2 mm from the sinotubular junction or aortic wall. Results: A total of 245 patients were evaluated (n = 117 TAVR using SAPIEN 3 at ≤90% implant depth, n = 66 TAVR using SAPIEN 3 at >90% implant depth, n = 31 SAVR, n = 31 SAVR with ARE). The proportion of patients where the simulated neo-skirt was below both coronary arteries was the highest in TAVR with implantation depth ≤90% (47.0%), intermediate in TAVR using SAPIEN 3 at >90% implant depth (22.7%) and SAVR (12.9%), and the lowest in SAVR with ARE (0%), (p < 0.001). Challenging anatomy for future TAVR was identified in 9.8% of TAVR at ≤90% implant depth, 28.8% of TAVR at >90% implant depth, 22.6% of SAVR, and 29.0% of SAVR with ARE (p < 0.001). Conclusions: Based on post-treatment computed tomography analysis, TAVR with SAPIEN 3 at implant depth ≤90% was the most repeatable initial intervention whereas SAVR with ARE did not improve the feasibility of future TAVR.