For decades, the most effective treatment option for patients with severe aortic stenosis has been surgical valve replacement.1,2 Bioprosthetic valves offer the primary benefit of not requiring lifelong warfarin therapy due to their lower thrombotic risk compared with mechanical valves (0.87% and 1.4% per year, respectively).3,4 Thus, the risk of bleeding is considerably lower in patients who have bioprosthetic valves.5 However, the leaflets of bioprosthetic valves have the potential to calcify and fibrose over time, leading to progressive stenosis. The accepted standard of care for replacing an aortic valve has long been surgical aortic valve replacement (SAVR). Transcatheter aortic valve replacement (TAVR) has emerged as a less invasive, safe and effective method of replacing valves in patients with severe aortic stenosis who are at intermediate or high risk of complications related to SAVR.6–9 Patients deemed to be at high surgical risk for re-operative surgical valve replacement are currently eligible for valve-in-valve (ViV) TAVR as a treatment for failed surgical tissue valves. However, ViV TAVR frequently results in less-than-ideal transcatheter heart valve expansion and can lead to patient–prosthesis mismatch (PPM), especially with small surgical valves. Bioprosthetic valve remodelling and bioprosthetic valve fracture can reduce the residual transvalvular gradient and optimally expand the transcatheter heart valve by using a non-compliant balloon and high-pressure inflation, respectively, to fracture or stretch the surgical valve ring, facilitating ViV TAVR. It is essential to precisely identify the surgical valve and ascertain whether it can be fractured or remodelled before considering bioprosthetic valve fracture/remodelling. Trifecta (Abbott) is a surgical valve that can be stretched or modified but not fractured. According to a Food and Drug Administration announcement, Abbott is no longer producing the Trifecta valve, used in aortic valve replacement surgery, because of reports of an increased risk of early structural valve deterioration.10 The complaint data indicate a shorter peak time to structural valve deterioration of 3–4 years, whereas the clinical trial data show a peak time to structural valve deterioration of 8 years.11
This report details the first reported case of ViV TAVR in a surgically placed non-fracturable valve in the Philippines, thus highlighting the possibility of avoiding re-operation in patients who have experienced degeneration of such valves.
Case Presentation
The patient was a 67-year-old man who was referred for the management of severe degeneration of a Trifecta 21 mm surgical bioprosthetic valve, which was implanted 10 years before admission, together with coronary artery bypass grafting with two saphenous vein grafts (one each to the left anterior descending artery and distal right coronary artery). One year before admission, the patient had an MI and underwent revascularisation with percutaneous coronary intervention/stenting of the native right coronary artery. Seven months before admission, the patient started to complain of progressive exertional dyspnoea. One month prior to admission, the patient began to have shortness of breath with minimal exertion, accompanied by easy fatiguability, pedal oedema, and two-pillow orthopnoea. His other medical comorbidities included hypercholesterolaemia, hypertension, gout and benign prostatic hypertrophy. The patient had no history of smoking and was not a heavy drinker of alcohol.
Due to his worsening symptoms, a 2D transthoracic echocardiogram was done. This demonstrated a left ventricular ejection fraction of 50%, grade 3 diastolic dysfunction, and an aortic valve area of 0.87 cm2, maximum velocity (Vmax) of 4.76 m/s, mean gradient of 56.2 mmHg with moderate to severe transvalvular and paravalvular aortic regurgitation (Figure 1 ). Due to his complicated history, the patient was referred to the Heart Team for assessment. Following careful discussions with the Heart Team on the options for valvular replacement, the patient opted for TAVR instead of redo SAVR.
The thoracoabdominal CT aortogram revealed a Trifecta surgical aortic valve, size 21 mm, with minimal subannular extension (Figure 2). Figure 3 shows the valve configuration from the time of implantation. A 23 mm Evolut PRO (Medtronic) was implanted under fluoroscopy guidance, with its delivery cone positioned at the ascending aorta. Following documentation of optimal valve position, the valve was carefully unsheathed and deployed using multiple guidance aortograms and transthoracic echocardiogram guidance. Optimal device implantation depth was achieved at 3–4 mm below the aortic annulus. There was evidence of a moderate paravalvular leak; hence, a VACS III 20 × 40 mm percutaneous transluminal valvuloplasty balloon catheter (Osypka) was used to post-dilate the implanted valve under rapid pacing at 160 BPM. Repeat 2D echo revealed mild paravalvular leak as shown in Figure 4. Follow-up aortography demonstrated a well-positioned aortic valve, no edge dissections, no coronary artery compromise and mild paravalvular leak. Such findings were also confirmed using transthoracic echocardiogram imaging (Figure 5). Follow-up simultaneous haemodynamic measurements using pigtail catheters at the left ventricle and another at the ascending aorta demonstrated an aortic pressure of 129/62 (mean arterial pressure: 86) mmHg and a left ventricular pressure of 136/0 (LV end diastolic pressure: 7) mmHg, showing a reduction in the peak-to-peak gradient to 7 mmHg.
Careful angiographic assessment of the left main artery was carried out using multiple angiographic images to ensure left central coronary artery patency before removal of the left main catheter and wire. Cerebral protection was also employed using the Sentinel Embolic Protection Device (Boston Scientific), which was deployed before valve deployment and carefully captured at the end of the procedure. Notably, debris was captured by the Sentinel baskets. The patient tolerated the procedure well with no clinical evidence of stroke.
One day post-procedure, the patient had stable vital signs but had a new systolic murmur. A repeat transthoracic echocardiogram revealed an aortic valve area of 1.2 cm², a Vmax of 5.21 m/s, and a mean gradient of 56 mmHg. Although no visible thrombus was seen, early bioprosthetic valve thrombosis was suspected. Enoxaparin was administered subcutaneously at a dose of 60 mg twice daily for 7 days and the patient was subsequently transitioned to apixaban 5 mg tablets twice daily. The patient was also maintained on 75 mg clopidogrel once a day due to his coronary stents. Inpatient cardiac rehabilitation was started without any untoward events. A repeat transthoracic echocardiogram performed 1 week later revealed an aortic valve area of 1.3 cm², a Vmax of 3.86 m/s, and a mean gradient of 32 mmHg, indicating a good response to anticoagulation. The patient was discharged clinically and improved on the eighth day of admission. Upon follow-up 2 weeks later, the patient was in New York Heart Association functional class I.
Discussion
Currently, there are no available data from randomised trials on the best treatment option for structural valve degeneration. Data from meta-analyses have shown a lower incidence of postoperative complications and 30-day mortality with similar 1-year and midterm mortality rates for ViV TAVR compared with redo-SAVR, despite increased rates of major bleeding, myocardial infarction, and severe prosthesis-patient mismatch.12–14 To date, ViV TAVR is the treatment of choice for patients with degenerated surgical bioprosthetic valves who are deemed to be at high or extreme surgical risk.15 Based on clinical trials indicating similar efficacy and safety profiles among older patients, regardless of risk categories, TAVR has gained popularity as a two-decade alternative to SAVR.16 According to current guidelines, patients aged ≥65 years in the US and ≥75 years in Europe are considered candidates for TAVR.1,2 Recent studies indicate that several countries have already experienced a significant rise in TAVR procedures among younger patients.16,17 Although there have been considerable improvements in the design and durability of both surgical and transcatheter bioprosthetic valves, degeneration and valve failure still frequently occur. Implanting a TAVR valve into a failing native valve has become a less invasive alternative to traditional heart valve replacement. In contrast, reoperation of a failed bioprosthetic valve has been linked to increased periprocedural risks and mortality.18,19 Numerous studies have demonstrated generally positive outcomes for TAVR-in-SAVR and TAVR-in-TAVR procedures, with lower rates of procedural complications and a significant improvement in valve function. Most complications were mild, and the success rates of TAVR-in-SAVR and TAVR-in-TAVR were comparable. Complications included elevated postprocedural gradients, coronary obstruction and leaflet thrombosis. Remarkably, mean echocardiographic gradients improved significantly and remained stable over the course of the year.20–22 At 1 month, event-free survival was 76%, and at 1 year, it was 69%.22 Reoperation may carry increased risks for patients who present with surgical bioprosthetic valve degeneration.23,24 For these patients, ViV TAVR has emerged as a safe and effective therapy.20,25 It is highly recommended that such complicated procedures be performed in highly specialised centres with experienced personnel.
Despite being a promising substitute for repeat SAVR, PPM remains an issue with ViV TAVR. Many approaches have been developed to prevent PPM after ViV TAVR. For example, using a transcatheter heart valve with supra-annular leaflet positioning (e.g. CoreValve [Evolut PRO]), as used in our patient, may increase the effective opening angle because the prosthetic leaflets are positioned supra-annularly. Aside from PPM, another consideration for increases in the transvalvular gradients in the early post-procedure phase is bioprosthetic valve thrombosis. This condition affects a significant number of post-TAVR patients, ranging from 4% to 15%.26 If the mean transvalvular gradient is ≥20 mmHg or has increased by more than 10 mmHg compared with baseline, valve thrombosis should be suspected. Early initiation of anticoagulant therapy can be beneficial in reversing the increase in gradients, as observed in this patient.
TAVR is now being introduced to younger patients in whom life expectancy may exceed the durability of bioprosthetic valves. ViV TAVR, as an alternative to redo-SAVR, is proving to be a gamechanger, including for those with non-fracturable valves such as the Trifecta valve. With the reduction in the use of mechanical valves even in younger patients, the need for chronic warfarin therapy and its accompanying bleeding risk can be avoided. Successful ViV TAVR in various settings is changing the landscape in the treatment of valvular heart disease, making the preference for bioprosthetic valves in initial valve replacement increasingly feasible.
SAVR remains the primary treatment for severe aortic stenosis in the Philippines, in particular at tertiary centres, such as The Medical City and the Philippine Heart Center, where cardiothoracic surgery programs are robust and supported by multidisciplinary heart teams.27,28 SAVR is still the preferred choice for younger patients, individuals with bicuspid valves, endocarditis or complex anatomy needing additional procedures.29 However, recently, transcatheter aortic valve implantation has seen rapid growth. St Luke’s Medical Center performed its 200th TAVR in 2022, highlighting the programme’s maturity and the increase in procedures.30 The Philippine Heart Center demonstrated scalability by conducting six transcatheter aortic valve implantation procedures in a single day in 2025.28 Regional expansion includes Davao Doctors Hospital, which completed its first transcatheter aortic valve implantation in 2024, and device diversification was evident with the Chinese General Hospital’s first use of the Edwards SAPIEN valve in the same year.31,32
These developments carry significant implications for structural valve deterioration. Bioprosthetic valves generally last 10–15 years, and as more Filipino patients undergo SAVR with tissue valves, ViV procedures will become increasingly important.29 With more than 200 cumulative TAVR cases at a single institution and expanding national infrastructure, centres in the Philippines are well-positioned to consider ViV as a safe alternative to repeat surgery.30 The case presented here, being the first ViV implantation in a surgically implanted Trifecta bioprosthesis, serves as a milestone in this rapidly advancing field of cardiovascular medicine.
Conclusion
ViV-TAVR provides a less invasive treatment option for patients with deteriorating bioprosthetic valves, including those with non-fracturable designs, and may offer advantages such as faster recovery and reduced perioperative morbidity compared with redo-SAVR. Early bioprosthetic valve thrombosis should be considered when a transvalvular gradient is elevated or rising, as prompt recognition is essential to prevent further valve dysfunction. In this case, early initiation of anticoagulation was associated with improved valve haemodynamics; however, these observations are limited to a single patient and should be interpreted with caution. Additional evidence from larger case series or prospective studies will be important to better define the safety, efficacy, and optimal management strategies for early bioprosthetic valve thrombosis following ViV-TAVR.