Who Needs Valve-in-Valve TAVR?

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Earnest Tate is 80 years old and lives in Selma, Alabama with his wife of 54 years, Norma Jean. 
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Aortic valve replacement is often used to treat cases of severe aortic stenosis, a condition involving the narrowing of the heart’s aortic valve. The valve can be replaced using one of two methods: surgical aortic valve replacement (SAVR) through open-heart surgery, or transcatheter aortic valve replacement (TAVR), which is less invasive. With both methods, your doctor may replace your diseased aortic valve with a manufactured mechanical valve made from durable materials, or a tissue valve made from animal tissue, called a bioprosthetic valve. Mechanical valves are long-lasting, but they almost always require the patient to take blood-thinning medication for the rest of their lives in order to prevent blood clots from interfering with the valve. Tissue valves, on the other hand, require no long-term medication. Over a number of years, however, bioprosthetic valves can start to break down and fail to function like they should. A second aortic valve replacement may be needed.

If your valve was initially replaced via open-heart surgery, undergoing a second one can be challenging, especially for certain individuals. So, a different procedure known as valve-in-valve TAVR may be recommended instead.

My Aortic Stenosis Confession: Susan

Understanding SAVR vs Valve-in-Valve TAVR

When you have severe aortic stenosis, your natural aortic valve becomes thickened and can’t fully open. This affects the amount of blood that your heart pumps out to the rest of your body. To try and make up for it, your heart tries to increase its pumping pressure, but if it remains untreated, the strain on your heart can become too much.

To avoid this, your doctor may suggest aortic valve replacement. Surgical aortic valve replacement (SAVR) requires an incision to be made in your chest, so the surgeon can access your heart. Your narrowed aortic valve is removed and a new one is inserted in its place. Though it sounds straightforward, open-heart surgery isn’t easy and recovery can be long.

If your replacement aortic valve starts to fail down the line, a redo SAVR procedure may be performed.

As an alternative to repeating SAVR, valve-in-valve TAVR is a minimally invasive procedure to replace a failed bioprosthetic heart valve. Instead of opening your chest, a flexible catheter with a new, folded-up replacement valve is inserted into a blood vessel and carefully advanced to the heart. Instead of taking out the dysfunctional valve, the new valve is expanded on top of it and starts to work in its place. The catheter is then removed. Recovery from valve-in-valve TAVR is typically much faster and less painful than SAVR.

Undergoing a Valve-in-Valve TAVR Assessment With Your Heart Team

So, why wouldn’t everyone who needs a second aortic valve replacement choose valve-in-valve TAVR? As of now, valve-in-valve TAVR is only approved for individuals at high risk of serious complications from undergoing surgery. Even though valve-in-valve TAVR is less invasive, it carries its own risks and requires a significant amount of testing and planning by a team of specialists in advance.

Characteristics that may make you a candidate for valve-in-valve TAVR include:

  • Older age
  • Additional significant medical conditions
  • Decreased ability of your body to fight infections or handle other stressors

The decision to proceed with a repeat SAVR or valve-in-valve TAVR should be made on a case-by-case basis. Talk to your heart team about the risks and benefits of each procedure for you.

To enhance the safety of valve-in-valve TAVR, if you’re an appropriate candidate, you’ll undergo a thorough evaluation prior to your procedure. Your heart team will examine the type and size of your previous replacement valve, as well as how it was implanted. You’ll require medical imaging to carefully evaluate the anatomy of your heart and blood vessels and allow your surgeon to determine the best type, size, and location for your new heart valve.

Though a redo SAVR is still the preferred method in most cases at this time, it’s possible valve-in-valve TAVR will become an option for more people in the future. Surgeons may even adapt the choices they make during the original surgical valve replacement to make valve-in-valve TAVR a more likely option for their patients years later.


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