# Mechanisms of Trifecta Valve Failure and Contemporary Approaches to Reintervention: Perceval vs Valve-in-Valve Transcatheter Aortic Valve Implantation

## TL;DR

This paper reviews Trifecta valve failure mechanisms and compares options for reintervention, such as using Perceval valves or transcatheter implantation.

## Contribution

The paper systematically analyzes Trifecta valve failure causes and evaluates contemporary reintervention strategies.

## Key findings

- Trifecta valve durability ranges from 4 to 9 years with re-operative incidence between 7.3% and 16.9%.
- Valve-in-valve transcatheter implantation is less favorable due to reduced effective orifice area risks.
- Perceval valves are recommended for small native annuli in Trifecta reintervention cases.

## Abstract

Aortic valve replacement with Trifecta valve provides a greater early haemodynamic performance with its externally mounted structure. However, failure rates in short-term post-implantation started to be reported, which brought great attention towards understanding the mechanisms of failure and optimal approaches for the replacement of the valve.

Fifty-seven studies published in PubMed/Medline, Cochrane Central Register of Controlled Trials (CENTRAL), Embase, and ClinicalTrials.gov were explored until January 2025. Original research articles or clinical trial reports that describe Trifecta failure and studies that describe valves used to approach failed Trifecta valves were included.

Durability of Trifecta has shown a median range of 4 to 9 years with re-operative incidence of 7.3% to 16.9%, respectively, with smaller valves (19-21 mm) degenerating quicker. Anti-calcification compounds used and valve design are the main causes for Trifecta structural valve degeneration. Modes of Trifecta failure soon after valve implantation are leaflet(s) dehiscence or tear along the stent post and, in the longer term post-operatively, include leaflet calcification and the fibrofatty circumferential pannus development in the inflow area.

We recommend that patients following Trifecta implantation with preoperative impaired kidneys, postoperative low effective orifice area (EOA) indexes, and prosthesis-patient mismatch be closely followed with echocardiograms to detect a possible Trifecta failure. Replacing a failed Trifecta valve with a sutureless Perceval could be an excellent option to approach a pre-existing small native annulus. Valve-in-valve transcatheter aortic valve implantation is a less favourable option due to the risk of a reduced EOA, though it may still be considered in selected patients with larger annuli.

The growing trend for implanting biological prostheses is to inhibit long-term oral anticoagulants and to increase the quality of life.