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PPM Risk in ViV-TAVI Small Prosthesis — EECC MCQ

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HardValvular Heart DiseasePPM Risk in ViV-TAVI Small ProsthesisEECC

A 65-year-old man has a bioprosthetic aortic valve replaced 12 years ago. Echocardiography shows severe bioprosthetic stenosis (mean gradient 45 mmHg, AVA 0.6 cm²). He is symptomatic but at high surgical risk (STS-PROM 10%). The original surgical valve inner diameter is 19 mm. What specific concern arises with valve-in-valve TAVI in small surgical prostheses?

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Correct answer: E — Patient-prosthesis mismatch (PPM) — the small inner diameter of the original surgical valve limits the effective orifice area of the transcatheter valve deployed within it, resulting in persistently elevated gradients; this is the major limitation of ViV-TAVI in small prostheses

Valve-in-valve (ViV) TAVI in small surgical bioprostheses (label size ≤21 mm, true internal diameter ≤19-20 mm) is technically feasible but carries a high risk of patient-prosthesis mismatch (PPM): the transcatheter valve deployed within the small rigid frame of the degenerated surgical valve cannot expand fully, resulting in a small effective orifice area and residual elevated gradients. PPM after ViV-TAVI is associated with worse outcomes. Strategies to mitigate: (1) valve fracture/cracking (intentional high-pressure balloon fracture of the surgical valve ring to allow greater expansion of the THV — increases EOA by ~30%); (2) BASILICA technique if coronary obstruction risk is also present; (3) supra-annular THV positioning; (4) consideration of redo SAVR with a larger prosthesis if surgical risk is acceptable. The 2025 ESC VHD Guidelines acknowledge PPM as the major limitation of ViV-TAVI in small prostheses.

Reference: ESC/EACTS (2025): VHD Guidelines