title: A second prosthesis as a procedural rescue option in trans-apical aortic valve implantation.
abstract: OBJECTIVE
  Trans-apical aortic valve implantation (TA-AVI) using the Edwards SAPIEN™ prosthesis has evolved to a routine procedure for selected high-risk elderly patients. In rare cases, misplacement of the SAPIEN™ valve (too low a position), dysfunction of the leaflets or perforation of the interventricular septum (ventricular septal defect, VSD) occurs and requires immediate implantation of a second prosthesis within the first one. Results of this 'bailout' maneuver have not been reported yet.
  
  
  METHODS
  Of 305 TA-AVI procedures, 15 patients required a second prosthesis due to dysfunctional leaflets (n = 6), low position (n = 7), or VSD (n = 2). Mean age was 82.5 ± 1.3 years, mean logistic EuroSCORE (European System for Cardiac Operative Risk Evaluation) was 45.5 ± 5.4, and Society of Thoracic Surgeons (STS) Score was 13.5 ± 1.5.
  
  
  RESULTS
  All second SAPIEN™ valves could be implanted successfully within the first one. The second prosthesis solved leaflet dysfunction, sealed the VSD (lower position of the second prosthesis), or corrected the initial misplacement (higher position of the second prosthesis) in all patients. Within 30 days, four patients died (low cardiac output n = 3, all with preoperative ejection fraction (EF) <35%; intestinal ischemia n = 1). Intra-operative echocardiogram and angiogram revealed mild paravalvular leak in three and none/trace in 12 patients. Transvalvular gradients were low despite the implantation of the second valve (P(max)/mean 13.7 ± 4.3/6.4 ± 2.0).
  
  
  CONCLUSIONS
  Placement of a second SAPIEN™ valve is a valuable 'bailout' technique in case of VSD, dysfunctional leaflets, or too low placement of the first prosthesis. The technique leads to an excellent functional result with low transvalvular gradients. The simple, straight, tubular stent design of the SAPIEN™ prosthesis may be the ideal design for such valve-in-valve procedures.
authors.affiliation: Department of Cardiac Surgery, Heartcenter University of Leipzig, Leipzig, Germany.
authors.forename: Jörg
authors.initials: J
authors.lastname: Kempfert
authors.forename: Ardawan J
authors.initials: AJ
authors.lastname: Rastan
authors.forename: Gerhard
authors.initials: G
authors.lastname: Schuler
authors.forename: Axel
authors.initials: A
authors.lastname: Linke
authors.forename: David
authors.initials: D
authors.lastname: Holzhey
authors.forename: Arnaud
authors.initials: A
authors.lastname: van Linden
authors.forename: Friedrich-W
authors.initials: FW
authors.lastname: Mohr
authors.forename: Thomas
authors.initials: T
authors.lastname: Walther
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D017548:Echocardiography, Transesophageal; D005260:Female; D005500:Follow-Up Studies; D006345:Heart Septal Defects, Ventricular / Q000209:etiology / Q000601:surgery; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000379:methods*; D006801:Humans; D008297:Male; D019060:Minimally Invasive Surgical Procedures / Q000009:adverse effects / Q000379:methods; D011474:Prosthesis Design; D011475:Prosthesis Failure; D011859:Radiography; D012086:Reoperation / Q000379:methods; D016896:Treatment Outcome