Dawn of a new era: The Matryoshka procedure

Abstract

Transcatheter aortic valve replacement (TAVR) has experienced a substantial usage growth in the past decade, owing partly to the improved design and durability of the bioprosthetic valves (BPVs), but also to the safety of the procedure and increased operator experience. Thereby, TAVR has transformed into the first‐choice therapy modality for patients with severe aortic stenosis who are nonsurgical candidates or have a high operative risk. Similarly, it may soon become the leading treatment modality for both patients with deteriorated surgical or transcatheter biological prosthesis and patients with native aortic valve disease who are suitable candidates for surgical valve replacement (SAVR) as demonstrated by two recent randomized trials. In addition, the safety and durability of TAVR compared to SAVR have been well‐documented. Furthermore, the short‐term mortality of TAVR for a structurally deteriorated surgical BPV (00.75%–4.6%) is comparable to the one corresponding to redo‐SAVR for the same purpose (2.5%–9%). All these favorable data are progressively encouraging the Heart Teams around the globe to offer TAVR is less surgically risky and younger patients. With this transformation of treatment of severe native aortic disease and severely deteriorated aortic BPVs, we will likely see longer survival periods with a good number of patients outliving the estimated durability of their percutaneously implanted prosthesis. In this issue of the Journal of Cardiac Surgery, Tomai et al. elegantly show a case study in which a valve‐in‐valve‐in‐valve TAVR, the so‐called Matryoshka procedure was performed successfully. The patient was a 73‐year‐old male who initially had an Edwards Perimount 21mm bioprosthesis surgically implanted. Unfortunately, this valve degenerated early and he underwent a redo SAVR with a suture‐less Livanova Perceval 23mm bioprosthesis, which was inserted inside of the frame of the Edwards Perimount valve 5 years later. Shortly after his second aortic valve replacement, he developed acute bacterial endocarditis of his aortic valve bioprosthetic complex and after a tumultuous clinical course; he was finally subjected to a valve‐in‐valve TAVR procedure with a 23‐mm Edwards Sapien3 bioprosthetic valve. This study adds to the initial piece of evidence on this area and provides us with another potential encounter type in the future. What do we learn from this case report from Tomai et al.? First, the rapid advancement in medicine is allowing patients to survive severe and complex aortic valve conditions. This global trend comes with another set of complications and management challenges for the interdisciplinary Heart Team. We are now facing not only TAVR in SAVR or redo‐TAVR cases but also more complex scenarios such as TAVR after TAVR in SAVR and TAVR after SAVR in SAVR and likely soon TAVR after redo‐TAVR. Second, feasible alternatives are emerging to redo aortic valve replacement in patients with BPV malfunction. These alternatives seem to be safe and effective. Third, preprocedural planning including a detailed imaging assessment of the aortic valve complex along with a comprehensive knowledge of the previous procedures including the characteristics of the BPVs used is paramount to obtain a successful clinical outcome. As you can see, the future is already here and comes with other challenging issues. The new complex scenarios above mentioned raise concerns regarding the following aspects: (1) long‐term durability of the newly implanted BPV, (2) risk of high transvalvular gradients and its impact on patient survival, (3) risk of coronary obstruction and aortic root rupture—especially after using techniques to optimize valve expansion, (4) impact of “burger TAVR” on BPV thrombosis, stroke and endocarditis, and (5) left ventricular anatomical and functional remodeling changes. In the end, the question is whether “the Matryoshka procedure” makes sense or not. In my opinion, it does. Considering all the above mentioned, it seems plausible; however, it comes with a lot of hopeful uncertainty. We will patiently wait for more data on patient outcomes. Until then, the decision to perform this procedure will be based on a thorough assessment of the risks and benefits and the consensus of the interdisciplinary Heart Team.