Transcatheter valve-in-valve implantation for deteriorated aortic bioprosthesis: initial clinical results and follow-up in a series of high-risk patients.

BACKGROUND: Transcatheter aortic valve implantation (TAVI) has become a viable alternative in maximum risk patients. For those patients requiring aortic valve re-replacement, the "valve-in-valve" concept has been described. We report our experience with transapical valve-in-valve implantation in 7 patients with deteriorated aortic bioprosthesis at 1-year follow up.

METHODS: Since November 2008, 210 patients received transapical TAVI due to severe aortic stenosis. Seven patients presented with deteriorated aortic valve bioprosthesis and received transapical valve-in-valve implantation. Mean age was 78.7±0.8 years. Preoperatively, all patients were at New York Heart Association (NYHA) functional class III. For risk estimation, the Society of Thoracic Surgeons (STS) and European System for Cardiac Operative Risk Evaluation (ES) risk scores were used and predicted high mortality (means±standard error of the mean: STSMortality 21.6±2.8%, ESadd 14.9±1.1, ESlog 52.6±9.0%). Mean follow-up time was 517±65 days (range, 280 to 799 days).

RESULTS: Six patients showed a severely deteriorated bioprosthesis in terms of a stenotic valve (aortic valve area: 0.64±0.04 cm2, maximum/mean developed transvalvular pressure gradient: dPmax 63.3±10.9 mm Hg, dPmean 40.4±5.6 mm Hg). One patient's deteriorated prosthesis was highly insufficient. Procedural success rate was 100%, mean procedure time was 46.7±12.3 minutes. Echocardiography revealed excellent hemodynamics of implanted prosthesis (dPmax 31.1±5.5 mm Hg; dPmean 19.4±4.3 mm Hg). Overall, postoperative course was uneventful. No patient died during follow-up, which ranged up to 26 months. All patients, except 1, remained in NYHA class I or II.

CONCLUSIONS: Our results demonstrate feasibility and safety of the transapical valve-in-valve approach with excellent hemodynamic and clinical results. Decision making in a multidisciplinary setting is mandatory. Further studies with more patients and longer follow-up are needed to identify candidates benefiting from transapical transcatheter valve-in-valve implantation.