title: Fluoroscopic guide to an ideal implant position for Sapien XT and CoreValve during a valve-in-valve procedure.
abstract: OBJECTIVE
  This study sought to provide a guide to the fluoroscopic appearances of various valve-in-valve (VIV) combinations by deploying a transcatheter heart valve (THV) within a degenerated surgical heart valve (SHV) in an ideal position.
  
  
  BACKGROUND
  VIV procedures are being increasingly performed with substantial experience acquired in treating degenerated SHV in the aortic position with Sapien/Sapien XT (Edwards Lifesciences Ltd., Irvine, California) and CoreValve/Evolute (Medtronic Inc., Minneapolis, Minnesota) valves. Although less invasive than conventional surgery, securing the THV in an optimal position within the SHV determines the success of this novel treatment.
  
  
  METHODS
  For VIV implantation, we selected appropriate Sapien XT and CoreValve/Evolute sizes depending on the internal diameter of the SHV. Implantation was performed in vitro. In case of the Sapien XT valve, it was deployed 4 to 5 mm below the sewing ring of the SHV, whereas the CoreValve/Evolute was deployed 5 mm below the level of the sewing ring. Photographs and fluoroscopic images of the various VIV combinations were obtained in side profile to study the ideal position and end-on profile to study the circularity of the THV.
  
  
  RESULTS
  Fluoroscopic images obtained in side profile highlighted the differences in various VIV combinations, as all SHV are unique in their fluoroscopic appearances. Also, all THV implants in various VIV combinations achieved a nearly circular shape.
  
  
  CONCLUSIONS
  To achieve an optimal result when considering VIV, it is important to be familiar with the structure and fluoroscopic appearances of the failed SHV, the THV used, and their combination.
authors.affiliation: Department of Cardiothoracic Surgery, St. Thomas' Hospital, London, United Kingdom. Electronic address: vnbapat@yahoo.com.
authors.forename: Vinnie N
authors.initials: VN
authors.lastname: Bapat
authors.forename: Rizwan Q
authors.initials: RQ
authors.lastname: Attia
authors.forename: Fortunata
authors.initials: F
authors.lastname: Condemi
authors.forename: Ravi
authors.initials: R
authors.lastname: Visagan
authors.forename: Maya
authors.initials: M
authors.lastname: Guthrie
authors.forename: Shelina
authors.initials: S
authors.lastname: Sunni
authors.forename: Martyn
authors.initials: M
authors.lastname: Thomas
mesh_terms: D001021:Aortic Valve / Q000000981:diagnostic imaging / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000000981:diagnostic imaging / Q000601:surgery / Q000628:therapy*; D001705:Bioprosthesis; D006328:Cardiac Catheterization / Q000295:instrumentation*; D005471:Fluoroscopy; D006350:Heart Valve Prosthesis; D019918:Heart Valve Prosthesis Implantation / Q000295:instrumentation* / Q000379:methods; D006801:Humans; D011474:Prosthesis Design; D015641:Radiography, Interventional / Q000379:methods*
keywords: SHV; THV; VIV; bioprosthesis; surgical heart valve; transcatheter aortic valve implantation; transcatheter heart valve; transcatheter valve; valve replacement; valve-in-valve