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a Assistance Publique-Hôpitaux de Paris, Service de Chirurgie Cardiovasculaire, Hôpital Européen Georges Pompidou, 20, rue Leblanc, Paris, 75908 France
b Service de Cardiologie, Hôpital Européen Georges Pompidou, 20, rue Leblanc, Paris, 75908 France
c Département d'Anesthésie-Réanimation, Hôpital Européen Georges Pompidou, 20, rue Leblanc, Paris, 75908 France
d Université René Descartes, Rue de l ‘école de medecine, Paris V, France
(Email: rzegdi{at}hotmail.com; rzegdi{at}hotmail.com).
| Dr Zegdi discloses that he has a financial relationship with Cormove.
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We read with interest the recent article of Walther and colleagues [1] in which the authors reported the case of an 82-year-old woman with a degenerated aortic, stented bioprosthesis. The patient benefited from a "valve-in-valve" implantation through a transapical approach. A 23-mm Edwards Sapien transcatheter heart valve was implanted inside a 21-mm Edwards Perimount conventional xenograft (Edwards Lifesciences, Irvine, CA). The procedure and the initial recovery were uneventful. The valve function was considered as good with no regurgitation and no residual stenosis.
Our team has been involved for many years in the development of new minimally invasive procedures in the field of valvular diseases, especially in cases of bioprosthetic failure due to structural degeneration [2]. In this particular setting, important findings were also obtained from an extensive ex vivo study on explanted degenerated bioprosthesis. We would like to share some of these results with the readers and make some comments on the present article, some of them requiring precisions from the authors:
"Prosthesis to prosthesis" mismatch is probably the most frequent problem that will be encountered by physicians. The tendency will be to implant a slightly oversized valved stent to achieve good anchorage and to minimize "peri-prosthetic" leaks. For a 21-mm Edwards Perimount bioprosthesis, the inner diameter is 17 mm in our experience and may be less in case of severe pannus. In the present case report, a 23-mm Edwards SAPIEN transcatheter heart valve was implanted in a 21-mm Edwards Perimount bioprosthesis, which represents a 6-mm oversizing. Such mismatch is responsible for valve distortion, a phenomenon that we have recently described [3]. Valve distortion is important to prevent because it may be responsible for a premature valve failure.The spatial orientation of the commissures of the newly implanted valved stent may be important to control. The "ideal" position is in face of the struts of the degenerated bioprosthesis to be treated. The "worst" is at mid-distance between two adjacent struts. In this configuration, due to the bi-concave aspect of the valved stent (as also described in the present case report), the intercommissural distance will be higher than it should be for an optimal valve functioning and probably valve durability.
The anatomic aspect of the bioprosthetic structural deterioration should also be considered. The regurgitant forms are probably the most favorable ones since valved stent deployment will not be hampered. Among the stenotic forms, one should distinguish between the exuberant ones on one hand, and the fibrotic (pannus) or the infiltrative fibrosclerotic ones. In our experimental study, stent misdeployment is unlikely to occur in the former with the current valved stents, but likely to be observed in the latter. The first human case of the percutaneously implanted valved stent was effectively a valve-in-valve procedure [4]. The final result was suboptimal (persistence of a residual stenosis) and this might be related, in our opinion, to the presence of excessive fibrosis (pannus), a common finding with valved conduits.
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 T. Walther, J. Kempfert, M. A. Borger, and M. Dehdashtian Reply Ann. Thorac. Surg., January 1, 2009; 87(1): 347 - 348. [Full Text] [PDF]
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