title: First percutaneous transcatheter aortic valve-in-valve implant with three year follow-up.
abstract: OBJECTIVE
  This study was conducted to report the clinical, hemodynamic, and iconographic outcomes of the longest survivor of the global CoreValve experience.
  
  
  BACKGROUND
  Early results of percutaneous heart valve (PHV) implantation for severe symptomatic aortic stenosis (AS) have been encouraging, with mid term survival up to 2 years; however longer durability term is unknown. Although a PHV has been implanted in a degenerated surgical bioprosthesis, the feasibility of a PHV-in-PHV has not been demonstrated.
  
  
  METHODS
  A patient with severe refractory heart failure due to severe aortic regurgitation (AR) and moderate AS, underwent CoreValve prosthesis implantation. The PHV was deployed too proximal into the left ventricular outflow tract, resulting in severe AR through the frame struts. Using the first PHV as a landmark, a second CoreValve was then deployed slightly distal to the first, with trivial residual paravalvular leak.
  
  
  RESULTS
  The second CoreValve expanded well with proper function. Transvalvular gradient was 8 mmHg. Both coronary ostia were patent. New mild to moderate mitral regurgitation occurred due to impingement of the anterior mitral leaflet by the first PHV. NYHA functional class improved from IV to II, maintained over the past 3 years. Echocardiography at 3 years showed normal functioning CoreValve-in-CoreValve prostheses, without AR or paravalvular leaks. Transvalvular gradient was 10 mmHg. Cardiac CT showed stable valve-in-valve protheses with no migration.
  
  
  CONCLUSIONS
  The CoreValve prosthesis has maintained proper function up to 3 years, with no structural deterioration or migration. Treating mixed aortic valve disease with predominant AR is feasible. The concept as well as durability of the first PHV-in-PHV has also been demonstrated.
authors.affiliation: Department of Cardiac and Vascular Interventional Services, Lenox Hill Heart and Vascular Institute of New York, New York, USA. cruiz@lenoxhill.net
authors.forename: Carlos E
authors.initials: CE
authors.lastname: Ruiz
authors.forename: Jean C
authors.initials: JC
authors.lastname: Laborde
authors.forename: Jose F
authors.initials: JF
authors.lastname: Condado
authors.forename: Paul T L
authors.initials: PT
authors.lastname: Chiam
authors.forename: Jose A
authors.initials: JA
authors.lastname: Condado
mesh_terms: D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000150:complications / Q000601:surgery; D001024:Aortic Valve Stenosis / Q000150:complications / Q000601:surgery; D001705:Bioprosthesis; D006328:Cardiac Catheterization; D017548:Echocardiography, Transesophageal; D005112:Extracorporeal Circulation; D005260:Female; D005500:Follow-Up Studies; D006333:Heart Failure / Q000209:etiology; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008875:Middle Aged; D016343:Monitoring, Intraoperative