Impact of angiographic valve expansion on the hemodynamic outcome in valve-in-valve transcatheter aortic valve replacement

Background: The durability of surgical aortic valve replacement prostheses can be limited due to structural valve deterioration over the years. Because of increased patient age and surgical risk, many of these patients are treated with valve-in-valve transcatheter aortic valve replacement (TAVR). Full expansion of the valve is often difficult to achieve in these patients, which might negatively affect the hemodynamic outcome. Aim: The aim was to investigate whether incomplete expansion of valve-in-valve TAVR correlates with an unfavorable hemodynamic outcome. Methods: A retrospective monocentric study with 152 patients who received a valve-in-valve TAVR between 2014 and 2024 at the University Heart Centre Freiburg—Bad Krozingen, Germany, was performed. The expansion and implantation depth of the TAVR prostheses were measured in the angiographic recordings and correlated with the postinterventional hemodynamic outcome. Results: 69.7% of the patients received self-expanding and 28.9% balloon-expandable TAVR prostheses during the valve-in-valve procedure. Under-expansion in the waist area of self-expanding valve prosthesis was associated with increased postinterventional mean pressure gradients. Post-dilation significantly improved the waist expansion in self-expanding valve prostheses (median increase 7.8%, p < 0.0001). Further, a correlation between implantation depth and waist expansion was observed in self-expanding valves (Spearman r − 0.4481, p < 0.0001), but not in balloon-expandable valves. Conclusion: Under-expansion of the waist area of self-expanding valve-in-valve TAVR was associated with an unfavorable hemodynamic outcome. A periinterventional measurement of the angiographic images after valve release might be useful to assess a relevant under-expansion and to assist in the indication for post-dilation. Clinical Trials Register: The study has been registered in the German Clinical Trials Register (DRKS-ID: DRKS00029242), date: 27/03/2023.