title: Determinants and outcomes of acute transcatheter valve-in-valve therapy or embolization: a study of multiple valve implants in the U.S. PARTNER trial (Placement of AoRTic TraNscathetER Valve Trial Edwards SAPIEN Transcatheter Heart Valve).
abstract: OBJECTIVE
  This study investigated the determinants and outcomes of acute insertion of a second transcatheter prosthetic valve (TV) within the first (TV-in-TV) or transcatheter valve embolization (TVE) after transcatheter aortic valve replacement (TAVR).
  
  
  BACKGROUND
  TAVR failure can occur with both TV-in-TV and TVE as a consequence of TAVR malpositioning. Only case reports and limited series pertaining to these complications have been reported to date.
  
  
  METHODS
  Patients undergoing TAVR in the PARTNER (Placement of AoRTic TraNscathetER Valve Trial Edwards SAPIEN Transcatheter Heart Valve) randomized trial (cohorts A and B) and accompanying registries were studied. Data were dichotomized for those with and without TV-in-TV or TVE, respectively.
  
  
  RESULTS
  From a total of 2,554 consecutive patients, 63 (2.47%) underwent TV-in-TV and 26 (1.01%) TVE. The indication for TV-in-TV was significant aortic regurgitation in most patients, often due not only to malpositioning but also to leaflet dysfunction. Despite similar aortic valve function on follow-up echoes, TV-in-TV was an independent predictor of 1-year cardiovascular mortality (hazard ratio [HR]: 1.86, 95% confidence interval [CI]: 1.03 to 3.38, p = 0.041), with a nonsignificant trend toward greater all-cause mortality (HR: 1.43, 95% CI: 0.88 to 2.33, p = 0.15). Technical and anatomical reasons accounted for most cases of TVE. A multivariable analysis found TVE to be an independent predictor of 1-year mortality (HR: 2.68, 95% CI: 1.34 to 5.36, p = 0.0055) but not cardiovascular mortality (HR: 1.30, 95% CI: 0.48 to 3.52, p = 0.60).
  
  
  CONCLUSIONS
  Acute TV-in-TV and TVE are serious sequelae of TAVR, often resulting in multiple valve implants. They carry an excess of mortality and are caused by anatomic and technical factors, which may be avoidable with judicious procedural planning.
authors.affiliation: Heart Institute, Cedars-Sinai Heart Institute, Los Angeles, California 90048, USA. Raj.Makkar@cshs.org
authors.forename: Raj R
authors.initials: RR
authors.lastname: Makkar
authors.forename: Hasan
authors.initials: H
authors.lastname: Jilaihawi
authors.forename: Tarun
authors.initials: T
authors.lastname: Chakravarty
authors.forename: Gregory P
authors.initials: GP
authors.lastname: Fontana
authors.forename: Samir
authors.initials: S
authors.lastname: Kapadia
authors.forename: Vasilis
authors.initials: V
authors.lastname: Babaliaros
authors.forename: Wen
authors.initials: W
authors.lastname: Cheng
authors.forename: Vinod H
authors.initials: VH
authors.lastname: Thourani
authors.forename: Joseph
authors.initials: J
authors.lastname: Bavaria
authors.forename: Lars
authors.initials: L
authors.lastname: Svensson
authors.forename: Susheel
authors.initials: S
authors.lastname: Kodali
authors.forename: Takahiro
authors.initials: T
authors.lastname: Shiota
authors.forename: Robert
authors.initials: R
authors.lastname: Siegel
authors.forename: E Murat
authors.initials: EM
authors.lastname: Tuzcu
authors.forename: Ke
authors.initials: K
authors.lastname: Xu
authors.forename: Rebecca T
authors.initials: RT
authors.lastname: Hahn
authors.forename: Howard C
authors.initials: HC
authors.lastname: Herrmann
authors.forename: Mark
authors.initials: M
authors.lastname: Reisman
authors.forename: Brian
authors.initials: B
authors.lastname: Whisenant
authors.forename: Scott
authors.initials: S
authors.lastname: Lim
authors.forename: Nirat
authors.initials: N
authors.lastname: Beohar
authors.forename: Michael
authors.initials: M
authors.lastname: Mack
authors.forename: Paul
authors.initials: P
authors.lastname: Teirstein
authors.forename: Charanjit
authors.initials: C
authors.lastname: Rihal
authors.forename: Pamela S
authors.initials: PS
authors.lastname: Douglas
authors.forename: Eugene
authors.initials: E
authors.lastname: Blackstone
authors.forename: Augusto
authors.initials: A
authors.lastname: Pichard
authors.forename: John G
authors.initials: JG
authors.lastname: Webb
authors.forename: Martin B
authors.initials: MB
authors.lastname: Leon
mesh_terms: D000369:Aged, 80 and over; D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000601:surgery; D021721:Balloon Occlusion; D006328:Cardiac Catheterization; D002318:Cardiovascular Diseases / Q000401:mortality; D005260:Female; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000379:methods* / Q000401:mortality; D006470:Hemorrhage / Q000453:epidemiology; D006801:Humans; D002546:Ischemic Attack, Transient / Q000453:epidemiology; D008297:Male; D015999:Multivariate Analysis; D061646:Operative Time; D017063:Outcome Assessment, Health Care; D010359:Patient Readmission / Q000706:statistics & numerical data; D011859:Radiography; D017678:Sex Distribution; D020521:Stroke / Q000401:mortality; D014463:Ultrasonography
keywords: AR; AT; BSA; CABG; CT; LV; TAVI; TAVR; TEE; THV; TIA; TV; TV-in-TV; TVE; V-in-V; aortic regurgitation; as-treated; body surface area; computed tomography; coronary artery bypass; embolization; left ventricular; outcomes; transcatheter aortic valve implantation; transcatheter aortic valve replacement; transcatheter heart valve; transcatheter prosthetic valve; transcatheter prosthetic valve within a transcatheter prosthetic valve; transcatheter valve; transcatheter valve embolization; transcatheter valve-in-surgical valve; transesophageal echocardiograms; transient ischemic attack; valve-in-valve