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

Abstract

BackgroundDevice malposition after transcatheter aortic valve replacement can cause significant clinical and hemodynamic instability. Aortic regurgitation following transcatheter heart valve (THV) implantation may be valvular due to prosthetic leaflet dysfunction or paravalvular due to poor annular sealing. When regurgitation is severe implantation of a second valve (THV-in-THV) may be effective by restoring normal leaflet function or extending the annular seal.Methods and results19 patients (age 80 ± 8 years, 53% male)underwent aortic balloon-expandable THV-in-THV implantation at 3 centres (St. Paul's Hospital, Vancouver, the Québec Heart and Lung Institute, Québec, and the Cleveland Clinic Foundation, Cleveland). Aortic regurgitation after the first implanted valve was paravalvular in 14 patients (implant too high in 2 patients, too low in 10 patients, and angiographically correct positioning in 2 patients) and transvalvular in 5 patients (4 Edwards SAPIEN valves, 1 Cribier Edwards valve). THV-in-THV implantation was successful in 17/19 (89%), while 2 patients (11%) required conversion to open heart surgery. None of the patients had transvalvular aortic regurgitation after the second procedure. Paravalvular aortic regurgitation was none in 4, mild in 11 and moderate to severe in 2 patients. Mean aortic valve gradient fell from 36 ± 11 mmHg to 13 ± 5 mmHg (P < 0.001) after implantation of the second valve. Mortality at 30 days and 1 year was 11.8% and 22.7%, respectively. At one year follow-up, all but one patient was NYHA class 1 or 2 and the mean gradient across the aortic valve remained stable (14 ± 5 mmHg).ConclusionsThis multicenter study shows that THV-in-THV implantation is feasible and results in satisfactory short and long term outcomes. BackgroundDevice malposition after transcatheter aortic valve replacement can cause significant clinical and hemodynamic instability. Aortic regurgitation following transcatheter heart valve (THV) implantation may be valvular due to prosthetic leaflet dysfunction or paravalvular due to poor annular sealing. When regurgitation is severe implantation of a second valve (THV-in-THV) may be effective by restoring normal leaflet function or extending the annular seal. Device malposition after transcatheter aortic valve replacement can cause significant clinical and hemodynamic instability. Aortic regurgitation following transcatheter heart valve (THV) implantation may be valvular due to prosthetic leaflet dysfunction or paravalvular due to poor annular sealing. When regurgitation is severe implantation of a second valve (THV-in-THV) may be effective by restoring normal leaflet function or extending the annular seal. Methods and results19 patients (age 80 ± 8 years, 53% male)underwent aortic balloon-expandable THV-in-THV implantation at 3 centres (St. Paul's Hospital, Vancouver, the Québec Heart and Lung Institute, Québec, and the Cleveland Clinic Foundation, Cleveland). Aortic regurgitation after the first implanted valve was paravalvular in 14 patients (implant too high in 2 patients, too low in 10 patients, and angiographically correct positioning in 2 patients) and transvalvular in 5 patients (4 Edwards SAPIEN valves, 1 Cribier Edwards valve). THV-in-THV implantation was successful in 17/19 (89%), while 2 patients (11%) required conversion to open heart surgery. None of the patients had transvalvular aortic regurgitation after the second procedure. Paravalvular aortic regurgitation was none in 4, mild in 11 and moderate to severe in 2 patients. Mean aortic valve gradient fell from 36 ± 11 mmHg to 13 ± 5 mmHg (P < 0.001) after implantation of the second valve. Mortality at 30 days and 1 year was 11.8% and 22.7%, respectively. At one year follow-up, all but one patient was NYHA class 1 or 2 and the mean gradient across the aortic valve remained stable (14 ± 5 mmHg). 19 patients (age 80 ± 8 years, 53% male)underwent aortic balloon-expandable THV-in-THV implantation at 3 centres (St. Paul's Hospital, Vancouver, the Québec Heart and Lung Institute, Québec, and the Cleveland Clinic Foundation, Cleveland). Aortic regurgitation after the first implanted valve was paravalvular in 14 patients (implant too high in 2 patients, too low in 10 patients, and angiographically correct positioning in 2 patients) and transvalvular in 5 patients (4 Edwards SAPIEN valves, 1 Cribier Edwards valve). THV-in-THV implantation was successful in 17/19 (89%), while 2 patients (11%) required conversion to open heart surgery. None of the patients had transvalvular aortic regurgitation after the second procedure. Paravalvular aortic regurgitation was none in 4, mild in 11 and moderate to severe in 2 patients. Mean aortic valve gradient fell from 36 ± 11 mmHg to 13 ± 5 mmHg (P < 0.001) after implantation of the second valve. Mortality at 30 days and 1 year was 11.8% and 22.7%, respectively. At one year follow-up, all but one patient was NYHA class 1 or 2 and the mean gradient across the aortic valve remained stable (14 ± 5 mmHg). ConclusionsThis multicenter study shows that THV-in-THV implantation is feasible and results in satisfactory short and long term outcomes. This multicenter study shows that THV-in-THV implantation is feasible and results in satisfactory short and long term outcomes.