Transcatheter aortic valve implantation for treatment of patients with degenerated aortic bioprostheses--valve-in-valve technique.

BACKGROUND: The management of patients with degeneration of surgical bioprosthetic valve replacement remains a challenge because of the higher risk of re-do aortic valve replacement. We present a case series of five patients with degenerated aortic bioprostheses treated with transfemoral transcatheter aortic valve implantation (TAVI).

METHODS: From December 2009 to May 2010, five patients with degenerated aortic valve bioprostheses (aortic valve area < 1 cm(2) or severe aortic regurgitation), an excessive operative risk (EuroSCORE ≥ 30%), symptoms of heart failure (NYHA ≥ III) and an internal diameter of bioprosthetic aortic valve 20.5 ± 0.5 mm were included. Procedures were performed without hemodynamic support using femoral arteries. Balloon valvuloplasty with a 20-mm balloon under rapid pacing was carried out before valve implantation. The 26-mm CoreValve prosthesis, 18-F-generation (Medtronic, Minneapolis, Minnesota) was inserted retrograde under fluoroscopic guidance. Invasive and echocardiographic measurements were done immediately before and after TAVI. Clinical followup and echocardiography were performed after procedure (mean followup 72 days ± 60, range: 176-30 days).

RESULTS: In all patients TAVI was successful with immediate decrease of transaortic peak-to-peak pressure (P = 0.002). Mild aortic regurgitation occurred in two patients and one patient received a new permanent pacemaker. Major adverse cardiac and cerebrovascular events did not arise. NYHA functional class improved in all patients and left ventricular ejection fraction increased (P = 0.019).

CONCLUSION: Our experiences with the valve-in-valve technique using the CoreValve prosthesis suggest that transfemoral TAVI is feasible in high risk patients with degenerated aortic bioprostheses.