Transcatheter valve-in-valve implantation for failed balloon-expandable transcatheter aortic valves

Stefan Toggweiler, David A Wood, Josep Rodés-Cabau, Samir Kapadia, Alexander B Willson, Jian Ye, Anson Cheung, Jonathon Leipsic, Ronald K Binder, Ronen Gurvitch, Melanie Freeman, Christopher R Thompson, Lars G Svensson, Eric Dumont, E Murat Tuzcu, John G Webb
JACC. Cardiovascular Interventions 2012, 5 (5): 571-577

OBJECTIVES: This study sought to evaluate outcomes after implantation of a second transcatheter heart valve (THV-in-THV) for acute THV failure.

BACKGROUND: Aortic regurgitation after transcatheter aortic valve replacement (TAVR) may be valvular due to prosthetic leaflet dysfunction or paravalvular due to poor annular sealing.

METHODS: Patients undergoing aortic balloon-expandable TAVR at 3 centers were prospectively evaluated at baseline, intraprocedurally, at hospital discharge, and annually.

RESULTS: Of 760 patients undergoing TAVR, 21 (2.8%) received a THV-in-THV implant due to acute, severe regurgitation. Aortic regurgitation was paravalvular in 18 patients and transvalvular in the remaining 3 patients. THV-in-THV implantation was technically successful in 19 patients (90%) and unsuccessful in 2 patients (10%), who subsequently underwent open heart surgery. Mortality at 30 days and 1 year was 14.3% and 24%, respectively. After successful THV-in-THV, mean aortic valve gradient fell from 37 ± 12 mm Hg to 13 ± 5 mm Hg (p < 0.01); aortic valve area increased from 0.64 ± 0.14 cm(2) to 1.55 ± 0.27 cm(2) (p < 0.01); and paravalvular aortic regurgitation was none in 4 patients, mild in 13 patients, and moderate in 2 patients. At 1-year follow-up, 1 patient had moderate and the others had mild or no paravalvular leaks. The mean transvalvular gradient was 15 ± 4 mm Hg, which was higher than in patients undergoing conventional TAVR (11 ± 4 mm Hg, p = 0.02).

CONCLUSIONS: THV-in-THV implantation is feasible and results in satisfactory short- and mid-term outcomes.

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