Changes of patient characteristics and procedural measures over 10 years in aortic valve-in-valve procedures for degenerated surgical bioprostheses

Tim Knochenhauer^1*Till Joscha Demal^1,2Oliver Bhadra¹Sebastian Ludwig³Nils Sörensen³Ina Von Der Heide³Laura Hannen³David Grundmann³Lisa Voigtlaender³Lara Waldschmidt³Johannes Schirmer³Simon Pecha³Evaldas Girdauskas^1,4Stefan Blankenberg^2,3Hermann Reichenspurner^1,2Niklas Schofer³Andreas Schaefer¹

• ¹Department of Cardiovascular Surgery, University Heart and Vascular Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
• ²German Centre for Cardiovascular Research, Partner Site Hamburg/Kiel/Lübeck, Hamburg, Germany
• ³Department of Cardiology, University Heart and Vascular Center, University Medical Center Hamburg, Hamburg, Germany
• ⁴Department of Cardiothoracic Surgery, Augsburg University Medical Centre, Augsburg, Germany

ABSTRACT Objectives Aortic valve-in-valve procedures for treatment of degenerated surgical bioprostheses are an established therapy. We herein evaluated how patients' risk profiles, procedural approaches, and early outcomes in these procedures changed over a period of 10 years. Methods Baseline, procedural, early outcome and echocardiographic parameters were retrospectively compared between three time periods (period 1: 2013-2016, period 2: 2017-2020, period 3: 2021-2023). Results Between 2013 and 2023, a total of 256 patients underwent valve-in-valve implantation in degenerated aortic bioprostheses at our center with a steady increase of patient numbers. Median age was 78.0 (IQR 72.2-82.4) years and unchanged over time. EuroSCORE II presented lower risk profiles in later periods (p=0.001). Access proportions changed with transfemoral access in 100% of patients in period 3 (p<0.001). Rates of BASILICA procedures (0% vs. 17.5% vs. 19.4%; p<0.001), and valve fracturing steadily increased (0% vs. 6.3% vs. 7.8%, p=0.058). Cerebral protection device use presented a distinct decline to 18.4% in period 3 (p<0.001). Procedure time and length of intensive-care unit stay decreased significantly over time. Early outcome parameters such as rates of permanent pacemaker implantation, bleeding, acute kidney injury, disabling stroke (0.0% vs. 1.3% vs. 1.0%, p=0.653), and device success (91.8% vs. 92.5% vs. 98.1%, p=0.123) were without significant changes over time. 30-day mortality decreased to 0% in period 3 (p=0.069). Conclusion Advancements in technical approaches have expanded the eligibility of patients previously considered unsuitable for aortic valve-in-valve procedures. Early outcomes were excellent with improvement over time, highlighting the procedure's clinical efficacy and safety.