Hemodynamic performance of valve-in-valve-in-valve implantation for transcatheter heart valve: an in vitro simulation study

BACKGROUND&OBJECTIVE: Valve-in-valve-in-valve (ViViV) implantation will be considered after the second valve deterioration as an increasing number of patients aged < 60 years undergo transcatheter aortic valve replacement (TAVR). We aimed to investigate the hemodynamic outcomes after ViViV procedures. METHOD: Evolut and Venus A with size of 23 mm and 26 mm were selected for the testing. Cardiovascular hydrodynamic tests were conducted using the in Vitro Pulse Duplicator system. RESULT: ViViV configuration of 26 mm-in-26 mm-in-26 mm demonstrates a larger effective orifice area (EOA) than the 23 mm-in-26 mm-in-26 mm configuration. The transvalvular mean pressure gradient (MPG) of three 26 mm combination were 8.3 ± 1.9 mmHg for Venus-A and 13.2 ± 1.6 mmHg for Evolut, which were acceptable. CONCLUSION: The ViViV valve combination employing three 26 mm Venus-A or Evolut self-expanding valves, as opposed to the 23 mm-in-26 mm-in-26 mm configuration, exhibited favorable hemodynamic performance as demonstrated by in the vitro testing.