Implantation Depth and Rotational Orientation Effect on Valve-in-Valve Hemodynamics and Sinus Flow

Background. This study evaluated the effect of transcatheter aortic valve implantation depth and rotation on pressure gradient (PG), leakage fractions (LF), leaflet shear stress, and sinus washout in an effort to understand factors that may dictate optimal positioning for valve-in-valve (ViV) procedures. Sinus flow stasis is often associated with prosthetic leaflet thrombosis. Although recent ViV in vitro studies highlighted potential benefits of transcatheter aortic valve supraannular implantation to minimize PGs, the relationship between transcatheter aortic valve depth and other determinates of valve function remains unknown. Among these, LFs, shear stress, and poor sinus washout have been associated with poorer valve outcomes. Methods. ViV hemodynamic performance was evaluated in vitro vs axial positions -9.8, -6.2, 0, and +6 mm and angular orientations 0, 30, 60, and 90 degrees in a degenerated surgical aortic valve. PGs, LFs, and sinus shear stress and washout were compared. Leaflet high-speed imaging and particle-image velocimetry were performed to elucidate hemodynamic mechanisms. Results. (1) The PG varies as a function of axial position, with supraannular deployments yielding a maximum benefit of 7.85 mm Hg less than PGs for subannular deployments irrespective of commissural alignment (p < 0.01); (2) in contrast, LF decreased in relationship to subannular deployment; and (3) at peak systole, sinus flow shear stress increased with deployment depth as did sinus washout with and without coronary flow. Conclusions. First, supraannular axial deployment is associated with lower PGs irrespective of commissural alignment. Second, subannular deployment is associated with more favorable sinus hemodynamics and less LF. Further in vivo studies are needed to substantiate these observations and facilitate optimal prosthesis positioning during ViV procedures. (C) 2018 by The Society of Thoracic Surgeons