Transapical aortic valve implantation after previous aortic valve replacement: clinical proof of the "valve-in-valve" concept.

OBJECTIVE: The "valve-in-valve" concept may be applied in patients with previously implanted biological aortic valve prostheses. There are few reports of individual cases and as yet no clinical proof of safety and feasibility in a larger group of patients. We report the single-center outcome of transapical implantation of aortic valves into degenerated biological aortic valve prostheses ("valve-in-valve") in very high-risk patients.

METHODS: Since October 2008, 14 patients were treated by transapical valve implantation into degenerated biological aortic valve prostheses. Edwards SAPIEN (Edwards Lifesciences, Irvine, Calif) transcatheter heart valves were used in all patients. Mean (± standard deviation) patient age was 73.3 ± 13.1 years. Mean (± standard deviation) Society of Thoracic Surgeons score was 21.9% ± 10.9% (range, 4.2%-42.2%), and logistic euroSCORE was 45.3% ± 22.2%. Preoperatively, all patients were in New York Heart Association functional class III or IV.

RESULTS: The procedural success was 100%. Preoperative transthoracic echocardiography mean transvalvular gradient was reduced from 37.1 ± 25.7 mm Hg to 13.1 ± 6.4 mm Hg, and mean aortic valve area increased from 0.68 ± 0.23 cm(2) to 1.35 ± 0.48 cm(2). There was no postoperative valve insufficiency. The postoperative course was short and uneventful in all but 1 patient. One patient underwent reoperation 3 months later because of endocarditis. Up to 20 months postoperatively, the patients were in New York Heart Association functional class I or II.

CONCLUSIONS: Transapical aortic valve implantation after previous aortic valve replacement was feasible and safe in our patients. The results are excellent with improvements in hemodynamics, but longer follow-up with more patients is needed.