title: Transcatheter aortic valve implantation in failed bioprosthetic surgical valves.
abstract: OBJECTIVE
  Owing to a considerable shift toward bioprosthesis implantation rather than mechanical valves, it is expected that patients will increasingly present with degenerated bioprostheses in the next few years. Transcatheter aortic valve-in-valve implantation is a less invasive approach for patients with structural valve deterioration; however, a comprehensive evaluation of survival after the procedure has not yet been performed.
  
  
  OBJECTIVE
  To determine the survival of patients after transcatheter valve-in-valve implantation inside failed surgical bioprosthetic valves.
  
  
  METHODS
  Correlates for survival were evaluated using a multinational valve-in-valve registry that included 459 patients with degenerated bioprosthetic valves undergoing valve-in-valve implantation between 2007 and May 2013 in 55 centers (mean age, 77.6 [SD, 9.8] years; 56% men; median Society of Thoracic Surgeons mortality prediction score, 9.8% [interquartile range, 7.7%-16%]). Surgical valves were classified as small (≤21 mm; 29.7%), intermediate (>21 and <25 mm; 39.3%), and large (≥25 mm; 31%). Implanted devices included both balloon- and self-expandable valves.
  
  
  METHODS
  Survival, stroke, and New York Heart Association functional class.
  
  
  RESULTS
  Modes of bioprosthesis failure were stenosis (n = 181 [39.4%]), regurgitation (n = 139 [30.3%]), and combined (n = 139 [30.3%]). The stenosis group had a higher percentage of small valves (37% vs 20.9% and 26.6% in the regurgitation and combined groups, respectively; P = .005). Within 1 month following valve-in-valve implantation, 35 (7.6%) patients died, 8 (1.7%) had major stroke, and 313 (92.6%) of surviving patients had good functional status (New York Heart Association class I/II). The overall 1-year Kaplan-Meier survival rate was 83.2% (95% CI, 80.8%-84.7%; 62 death events; 228 survivors). Patients in the stenosis group had worse 1-year survival (76.6%; 95% CI, 68.9%-83.1%; 34 deaths; 86 survivors) in comparison with the regurgitation group (91.2%; 95% CI, 85.7%-96.7%; 10 deaths; 76 survivors) and the combined group (83.9%; 95% CI, 76.8%-91%; 18 deaths; 66 survivors) (P = .01). Similarly, patients with small valves had worse 1-year survival (74.8% [95% CI, 66.2%-83.4%]; 27 deaths; 57 survivors) vs with intermediate-sized valves (81.8%; 95% CI, 75.3%-88.3%; 26 deaths; 92 survivors) and with large valves (93.3%; 95% CI, 85.7%-96.7%; 7 deaths; 73 survivors) (P = .001). Factors associated with mortality within 1 year included having small surgical bioprosthesis (≤21 mm; hazard ratio, 2.04; 95% CI, 1.14-3.67; P = .02) and baseline stenosis (vs regurgitation; hazard ratio, 3.07; 95% CI, 1.33-7.08; P = .008).
  
  
  CONCLUSIONS
  In this registry of patients who underwent transcatheter valve-in-valve implantation for degenerated bioprosthetic aortic valves, overall 1-year survival was 83.2%. Survival was lower among patients with small bioprostheses and those with predominant surgical valve stenosis.
authors.affiliation: St Paul's Hospital, Vancouver, British Columbia, Canada.
authors.forename: Danny
authors.initials: D
authors.lastname: Dvir
authors.affiliation: St Paul's Hospital, Vancouver, British Columbia, Canada.
authors.forename: John G
authors.initials: JG
authors.lastname: Webb
authors.affiliation: German Heart Center, Munich, Germany.
authors.forename: Sabine
authors.initials: S
authors.lastname: Bleiziffer
authors.affiliation: Deutsches Herzzentrum Berlin, Berlin, Germany.
authors.forename: Miralem
authors.initials: M
authors.lastname: Pasic
authors.affiliation: Washington Hospital Center, Washington, DC.
authors.forename: Ron
authors.initials: R
authors.lastname: Waksman
authors.affiliation: Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York.
authors.forename: Susheel
authors.initials: S
authors.lastname: Kodali
authors.affiliation: St Paul's Hospital, Vancouver, British Columbia, Canada.
authors.forename: Marco
authors.initials: M
authors.lastname: Barbanti
authors.affiliation: San Raffaele Scientific Institute, Milan, Italy.
authors.forename: Azeem
authors.initials: A
authors.lastname: Latib
authors.affiliation: Asklepios Clinics St Georg, Hamburg, Germany.
authors.forename: Ulrich
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authors.lastname: Schaefer
authors.affiliation: Quebec Heart and Lung Institute, Quebec City, Quebec, Canada.
authors.forename: Josep
authors.initials: J
authors.lastname: Rodés-Cabau
authors.affiliation: University Heart Center Hamburg, Hamburg, Germany.
authors.forename: Hendrik
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authors.lastname: Treede
authors.affiliation: Department of Interventional Cardiology at McGill University Health Centre, Montreal, Quebec, Canada.
authors.forename: Nicolo
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authors.lastname: Piazza
authors.affiliation: Sussex Cardiac Centre, Brighton, England.
authors.forename: David
authors.initials: D
authors.lastname: Hildick-Smith
authors.affiliation: Hospital Bichat, Paris, France.
authors.forename: Dominique
authors.initials: D
authors.lastname: Himbert
authors.affiliation: Kerckhoff Heart Center, Bad Nauheim, Germany.
authors.forename: Thomas
authors.initials: T
authors.lastname: Walther
authors.affiliation: Universitaetsklinikum Regensburg, Regensburg, Germany.
authors.forename: Christian
authors.initials: C
authors.lastname: Hengstenberg
authors.affiliation: Odense University Hospital, Odense, Denmark.
authors.forename: Henrik
authors.initials: H
authors.lastname: Nissen
authors.affiliation: University of Heidelberg, Heidelberg, Germany.
authors.forename: Raffi
authors.initials: R
authors.lastname: Bekeredjian
authors.affiliation: Hemodynamic and Invasive Cardiology Unit, IRCCS Istituto Clinico Humanitas, Milan, Italy.
authors.forename: Patrizia
authors.initials: P
authors.lastname: Presbitero
authors.affiliation: University Hospital of Lausanne, Lausanne, Switzerland.
authors.forename: Enrico
authors.initials: E
authors.lastname: Ferrari
authors.affiliation: Sheba Medical Center, Ramat Gan, Israel.
authors.forename: Amit
authors.initials: A
authors.lastname: Segev
authors.affiliation: Leids Universitair Medisch Centrum, Leiden, the Netherlands.
authors.forename: Arend
authors.initials: A
authors.lastname: de Weger
authors.affiliation: Bern University Hospital, Bern, Switzerland.
authors.forename: Stephan
authors.initials: S
authors.lastname: Windecker
authors.affiliation: Royal Brompton Hospital, London, England.
authors.forename: Neil E
authors.initials: NE
authors.lastname: Moat
authors.affiliation: Department of Cardiac, Thoracic, and Vascular Sciences, University of Padua, Padua, Italy.
authors.forename: Massimo
authors.initials: M
authors.lastname: Napodano
authors.affiliation: University Heart Center Dresden, Dresden, Germany.
authors.forename: Manuel
authors.initials: M
authors.lastname: Wilbring
authors.affiliation: G. Pasquinucci Hospital, Massa, Italy.
authors.forename: Alfredo G
authors.initials: AG
authors.lastname: Cerillo
authors.affiliation: St George's Hospital, London, England.
authors.forename: Stephen
authors.initials: S
authors.lastname: Brecker
authors.affiliation: Clinique Pasteur, Toulouse, France.
authors.forename: Didier
authors.initials: D
authors.lastname: Tchetche
authors.affiliation: Hopital Jacques Cartier, Massy, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Lefèvre
authors.affiliation: Ospedale Niguarda Ca'Granda, Milan, Italy.
authors.forename: Federico
authors.initials: F
authors.lastname: De Marco
authors.affiliation: Azienda Ospedaliere Spedali Civili di Brescia, Brescia, Italy.
authors.forename: Claudia
authors.initials: C
authors.lastname: Fiorina
authors.affiliation: Azienda Ospedaliero-Universitaria Pisana, Pisa, Italy.
authors.forename: Anna Sonia
authors.initials: AS
authors.lastname: Petronio
authors.affiliation: Hospital de Santa Cruz, Lisbon, Portugal.
authors.forename: Rui C
authors.initials: RC
authors.lastname: Teles
authors.affiliation: Clinical Institute S. Ambrogio, Milan, Italy.
authors.forename: Luca
authors.initials: L
authors.lastname: Testa
authors.affiliation: St George's Hospital, London, England.
authors.forename: Jean-Claude
authors.initials: JC
authors.lastname: Laborde
authors.affiliation: Columbia University Medical Center/New York Presbyterian Hospital and the Cardiovascular Research Foundation, New York, New York.
authors.forename: Martin B
authors.initials: MB
authors.lastname: Leon
authors.affiliation: Rabin Medical Center and Tel Aviv University, Tel Aviv, Israel.
authors.forename: Ran
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authors.lastname: Kornowski
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D001021:Aortic Valve / Q000601:surgery*; D001022:Aortic Valve Insufficiency / Q000601:surgery*; D001024:Aortic Valve Stenosis / Q000601:surgery*; D001705:Bioprosthesis; D006328:Cardiac Catheterization; D005260:Female; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D008875:Middle Aged; D011474:Prosthesis Design; D011475:Prosthesis Failure; D012042:Registries; D016019:Survival Analysis; D016896:Treatment Outcome