Cardiovascular Surgery Department, Centre Hôpitalier Universitaire Vaudois, University Hospital of Lausanne, CH-1011 Lausanne, Switzerland.
Eur J Cardiothorac Surg. 2012 Mar;41(3):485-90. doi: 10.1093/ejcts/ezr027. Epub 2011 Oct 18.
Standard surgical aortic valve replacement with a biological prosthesis remains the treatment of choice for low- and mid-risk elderly patients (traditionally >65 years of age) suffering from severe symptomatic aortic valve stenosis or insufficiency, and for young patients with formal contraindications to long-lasting anticoagulation. Unfortunately, despite the fact that several technical improvements have noticeably improved the resistance of pericardial and bovine bioprostheses to leaflet calcifications and ruptures, the risk of early valve failure with rapid degeneration still exists, especially for patients under haemodialysis and for patients <60 years of age at the time of surgery. Until now, redo open heart surgery under cardiopulmonary bypass and on cardioplegic arrest was the only available therapeutic option in case of bioprosthesis degeneration, but it carried a higher surgical risk when elderly patients with severe concomitant comorbidities were concerned. Since a few years, the advent of new transcatheter aortic valve procedures has opened new horizons in cardiac surgery and, in particular, the possibility of implanting stented valves within the degenerated stented bioprosthesis, the so-called 'valve-in-valve' (VinV) concept, has become a clinical practice in experienced cardiac centres. The VinV procedure represents a minimally invasive approach dedicated to high-risk redo patients, and published preliminary reports have shown a success rate of 100% with absence of significant valvular leaks, acceptable transvalvular gradients and low complication rate. However, this procedure is not riskless and the most important concerns are about the size mismatch and the right positioning within the degenerated bioprosthesis. In this article, we review the limited available literature about VinV procedures, underline important technical details for the positioning and provide guidelines to prevent valve-prosthesis mismatch comparing the three sizes of the only commercially available transapical device, the Edwards Sapien, with the inner diameter of three of the most commonly used stented bioprostheses.
标准的外科主动脉瓣置换术，使用生物假体，仍然是低危和中危老年患者（传统上>65 岁）患有严重症状性主动脉瓣狭窄或关闭不全的治疗选择，也是年轻患者有明确抗凝禁忌证的治疗选择。不幸的是，尽管几项技术改进显著提高了心包和牛生物假体瓣叶钙化和破裂的阻力，但早期瓣膜失功和快速退化的风险仍然存在，特别是对于接受血液透析的患者和手术时年龄<60 岁的患者。到目前为止，在体外循环和心脏停搏下进行再次开胸心脏手术是生物假体退化的唯一可用治疗选择，但对于伴有严重合并症的老年患者，手术风险更高。几年前，新的经导管主动脉瓣手术的出现为心脏手术开辟了新的前景，特别是在退化的支架生物假体内植入支架瓣膜的可能性，即所谓的“瓣中瓣”（VinV）概念，在有经验的心脏中心已成为一种临床实践。VinV 手术是一种针对高危再次手术患者的微创方法，已发表的初步报告显示成功率为 100%，无明显瓣膜渗漏，跨瓣梯度可接受，并发症发生率低。然而，该手术并非无风险，最重要的关注点是大小不匹配和在退化生物假体中的正确定位。本文回顾了关于 VinV 手术的有限文献，强调了定位的重要技术细节，并比较了唯一商业化的经心尖装置 Edwards Sapien 的三种尺寸，提供了防止瓣膜-假体不匹配的指南，该装置与三种最常用的支架生物假体的内径相匹配。
