Valve-in-valve transcatheter aortic valve replacement for the degenerated rapid deployment PercevalTM prosthesis: technical considerations

: Rapid deployment aortic valve prostheses or “sutureless valves” (SV) present a favorable hemodynamic and clinical safety profile but remain sensitive to structural valve degeneration (SVD) leading to valve dysfunction. In patients with SVD, valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has become the preferred approach because of its high procedural success rate and the inherent risk of redo-surgery in an often-elderly population. However, careful consideration of anatomical characteristics and features of the surgical prosthesis is needed to assess feasibility of the ViV procedure, including meticulous attention to avoid coronary obstruction, device malpositioning, and high residual transprosthetic gradients. We systematically describe technical considerations for the transcatheter treatment of failing PercevalTM SV. By design, PercevalTM has the potential to serve as an ideal docking station for a transcatheter ViV procedure, offering a clearly visible radiopaque frame, circumferential expansion capabilities, and a low risk of coronary obstruction and sinus sequestration. We describe procedural tips and tricks and provide our own case experience. In a series of 784 PercevalTM implants, incidence rate of severe SVD was 0.54% per patient year (15 patients), of which only 9 were scheduled for and underwent successful ViV TAVR. Treatment resulted in all patients in clinical improvement and significant reduction of transprosthetic gradients and no residual aortic valve regurgitation.