Feasibility of valve-in-root transcatheter aortic valve implantation in patients with prior aortic root replacement and repair

Alicja Zientara¹^,², MD; Fabio Brizzi¹^,², MD; Constantin von zur Mühlen²^,³, MD; Hans Bruijnen⁴, MD; Maximilian Kreibich¹^,², MD, MHBA; Tim Berger¹^,², MD, MBA; Stoyan Kondov¹^,², MD; Matthias Siepe⁵, MD; Bartosz Rylski⁶, MD; Julia Benk¹^,², MD; Friedhelm Beyersdorf¹^,², MD; Jonathan Rilinger²^,³, MD; Alexander Maier²^,³, MD; Vera Oettinger²^,³, MD, MSc; Dirk Westermann²^,³, MD; Martin Czerny¹^,², MD, MBA; Roman Gottardi¹^,², MD, MBA

Abstract

Background: Despite excellent long-term results, patients who have undergone valve-sparing root repair (VSRR) or a Bio-Bentall procedure may require a future secondary valve-related intervention.

Aims: We aimed to assess the feasibility of transcatheter valve-in-root procedures in patients who have previously undergone either a VSRR or a root replacement with a Bio-Bentall, in anticipation of lifetime management.

Methods: Between 2012 and 2022, 537 patients underwent a VSRR or a Bio-Bentall procedure in our institution. In 363 patients, a postoperative computed tomography angiography was available (VSRR n=250; Bio-Bentall n=113) to evaluate the feasibility of a transcatheter valve-in-root implantation. Annulus area, annulus-to-coronary distance, coronary ostium size, and the valve-to-coronary distance (VTC) were measured using dedicated software.

Results: After VSRR, 4.8% of patients had an annulus area over 840 mm², thus being unsuitable for a valve-in-root procedure. In 12.4% of cases after a Bio-Bentall procedure, the annulus area was below 300 mm², which complicates valve-in-root implantation due to potential patient-prosthesis mismatch. The annulus-to-coronary distance for both coronary arteries was significantly higher after VSRR compared to Bio-Bentall (right coronary artery: 18.0±5.8 mm vs 12.5±5.4 mm; p<0.001; left coronary artery [LCA]: 11.6±4.6 mm vs 8.0±4.5 mm; p<0.001). Out of a total of 98 coronary ostia located below the upper frame level, 63.3% had a VTC below 4 mm. The VTC to the LCA was significantly larger after Bio-Bentall with a Valsalva graft, with a median of 4.95 (interquartile range [IQR] 4.2-5.9) mm compared with 3.1 (IQR 2.3-4.2) mm (p<0.001) in patients who had a straight graft implanted.

Conclusions: The feasibility of a future transcatheter valve-in-root procedure depends on the anatomical conditions of the aortic root after the initial operation. A high reimplantation of coronary ostia, the choice of the vascular graft, and a foresighted valve sizing may facilitate a future transcatheter valve-in-root implantation.

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