title: Procedural and clinical outcomes of the valve-in-valve technique for severe aortic insufficiency after balloon-expandable transcatheter aortic valve replacement.
abstract: OBJECTIVE
  To describe the clinical and procedural outcomes of patients treated with the valve-in-valve technique for severe aortic insufficiency (AI) after balloon-expandable transcatheter aortic valve replacement (TAVR).
  
  
  BACKGROUND
  Severe AI immediately after valve implantation is a notable complication of TAVR. It can be treated with a valve-in-valve technique which involves deploying a second valve within the first one to crush the leaflets of the first implant leaving a new functional valve.
  
  
  METHODS
  We analyzed data on 142 consecutive patients at our institution undergoing TAVR with the Sapien valve between November of 2007 and April of 2011. Etiologies of acute AI, procedural and intermediate term clinical outcomes were reported for those in whom a valve-in-valve procedure was necessary. Post-hoc analysis of these cases with C-THV imaging (Paieon Medical Ltd.) was performed to elucidate the mechanism for successful AI treatment.
  
  
  RESULTS
  A total of 5 of 142 (3.5%) patients were treated with the valve-in-valve technique. Etiologies of the aortic valve insufficiency included bioprosthesis malposition (n = 3), valve dysfunction (n = 1), and valve undersizing (n = 1). With placement of the second valve, the first valve dimensions increased to approach the nominal valve size while the second valve size remained less than nominal.
  
  
  CONCLUSIONS
  The valve-in-valve technique is an appropriate bailout measure for patients with acute valvular AI after balloon-expandable TAVR.
authors.affiliation: Department of Medicine, Cardiovascular Divison, University of Pennsylvania, Philadelphia, Pennsylvania, USA.
authors.forename: Jay
authors.initials: J
authors.lastname: Giri
authors.forename: Anna E
authors.initials: AE
authors.lastname: Bortnick
authors.forename: Tyler
authors.initials: T
authors.lastname: Wallen
authors.forename: Elizabeth
authors.initials: E
authors.lastname: Walsh
authors.forename: Amr
authors.initials: A
authors.lastname: Bannan
authors.forename: Nimesh
authors.initials: N
authors.lastname: Desai
authors.forename: Wilson Y
authors.initials: WY
authors.lastname: Szeto
authors.forename: Joseph
authors.initials: J
authors.lastname: Bavaria
authors.forename: Howard C
authors.initials: HC
authors.lastname: Herrmann
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000209:etiology / Q000628:therapy*; D001024:Aortic Valve Stenosis / Q000628:therapy*; D006328:Cardiac Catheterization / Q000009:adverse effects* / Q000295:instrumentation; D002404:Catheterization; D018618:Echocardiography, Doppler, Color; D017548:Echocardiography, Transesophageal; D005260:Female; D005471:Fluoroscopy; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects* / Q000295:instrumentation / Q000379:methods; D006801:Humans; D021621:Imaging, Three-Dimensional; D008297:Male; D011474:Prosthesis Design; D011857:Radiographic Image Interpretation, Computer-Assisted; D012720:Severity of Illness Index; D016896:Treatment Outcome