Structural Valve Degeneration and Failure in Transcatheter and Surgical Bioprosthesis

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Background

Bioprosthetic heart valve are now increasingly used in preference to mechanical valves but valve dysfunction may occur over time, resulting in limited long-term durability.
Since introduction in 2002 and broader clinical use in 2007, penetration of transcatheter aortic valve implantation (TAVI) has grown exponentially. However, our knowledge concerning clinical outcomes of TAVI beyond 5 years is still limited. Furthermore, a significant challenge when comparing the durability of different types of bioprostheses is the lack of a standardized terminology for the definition of a degenerated valve. This issue becomes particularly important when we try to compare the degeneration rate of surgically inserted and transcatheter bioprosthetic valves.

Recently, a Task Force from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) endorsed by the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS) recommended the use of bioprosthetic valve failure as the main outcome of interest in studies assessing the long-term performance of transcatheter aortic valve implantation and surgical aortic valve replacement.
The term bioprosthetic valve failure integrates severe structural valve deterioration, whatever the etiology, with its clinical consequences, thereby avoiding over-interpretation of valve-related outcomes in asymptomatic patients with no clinical impact. Structural valve degeneration (SVD) includes permanent intrinsic changes of the valve (i.e. leaflet tear, calcification, pannus deposition, flail, or fibrotic leaflet) leading to degeneration and/or dysfunction, which in turn may result in stenosis or intra-prosthetic regurgitation.

Valve-in-valve procedures have been identified as a feasible, less-invasive treatment option for patients with degenerated surgically implanted bioprostheses, and the ACC/AHA guidelines currently recommend this approach in high-risk patients with aortic bioprosthesis dysfunction. However, valve-in-valve procedures differ from conventional TAVI procedures in regard to
an increased risk for high residual gradients and coronary obstruction, particularly approaching some challenging type of valves.

The significant increase in the use of aortic bioprostheses in recent times will inevitably lead to
rising numbers of patients diagnosed with SVD in the next decade. This should stimulate further research efforts in the prevention and treatment of this entity, particularly if we embrace the possibility of treating younger patients with biological (instead of mechanical) valves.

The purpose of this Research Topic is to summarize the available data on the durability of both surgical and transcatheter aortic bioprosthesis, as well as to provide an overview of new definitions, causes and mechanisms of structural valve degeneration and bioprosthetic failure, diagnostic algorithm, and to evaluate current treatment options for valve failure, including tips and tricks in challenging situations.

Keywords: Structural Valve Degeneration, Transcatheter Heart Valve, Surgical Bioprosthesis, Valve Dysfunction, Bioprosthesis Failure, Durability, Long-term outcomes

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