title: Transcatheter valve-in-valve implantation for failed balloon-expandable transcatheter aortic valves.
abstract: OBJECTIVE
  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.
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Stefan
authors.initials: S
authors.lastname: Toggweiler
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: David A
authors.initials: DA
authors.lastname: Wood
authors.affiliation: Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
authors.forename: Josep
authors.initials: J
authors.lastname: Rodés-Cabau
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Samir
authors.initials: S
authors.lastname: Kapadia
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Alexander B
authors.initials: AB
authors.lastname: Willson
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Jian
authors.initials: J
authors.lastname: Ye
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Anson
authors.initials: A
authors.lastname: Cheung
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Jonathon
authors.initials: J
authors.lastname: Leipsic
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Ronald K
authors.initials: RK
authors.lastname: Binder
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Ronen
authors.initials: R
authors.lastname: Gurvitch
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Melanie
authors.initials: M
authors.lastname: Freeman
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada.
authors.forename: Christopher R
authors.initials: CR
authors.lastname: Thompson
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: Lars G
authors.initials: LG
authors.lastname: Svensson
authors.affiliation: Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada.
authors.forename: Eric
authors.initials: E
authors.lastname: Dumont
authors.affiliation: Department of Cardiovascular Medicine, Cleveland Clinic, Cleveland, Ohio.
authors.forename: E Murat
authors.initials: EM
authors.lastname: Tuzcu
authors.affiliation: Department of Cardiology, Cardiac Surgery, St. Paul's Hospital, University of British Columbia, Vancouver, British Columbia, Canada. Electronic address: john.webb@vch.ca.
authors.forename: John G
authors.initials: JG
authors.lastname: Webb
mesh_terms: D000208:Acute Disease; D000368:Aged; D000369:Aged, 80 and over; D001022:Aortic Valve Insufficiency / Q000175:diagnosis / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D001024:Aortic Valve Stenosis / Q000401:mortality / Q000628:therapy*; D002170:Canada; D006328:Cardiac Catheterization / Q000295:instrumentation* / Q000401:mortality; D016009:Chi-Square Distribution; D018618:Echocardiography, Doppler, Color; D017548:Echocardiography, Transesophageal; D005240:Feasibility Studies; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000009:adverse effects / Q000295:instrumentation* / Q000379:methods* / Q000401:mortality; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D009820:Ohio; D011237:Predictive Value of Tests; D011446:Prospective Studies; D011474:Prosthesis Design; D011475:Prosthesis Failure; D019233:Retreatment; D018570:Risk Assessment; D012307:Risk Factors; D012720:Severity of Illness Index; D013997:Time Factors; D017211:Treatment Failure