title: Transcatheter valve-in-valve therapy using 6 different devices in 4 anatomic positions: Clinical outcomes and technical considerations.
abstract: OBJECTIVE
  Transcatheter valve-in-valve implantation (ViV) is emerging as a novel treatment option for patients with deteriorated bioprostheses. We report our cumulative experience using 6 types of transcatheter heart valves (THVs) in all anatomic positions.
  
  
  METHODS
  Seventy-five consecutive patients (74.1 ± 12.9 years, 50.7% male (38/75), logEuroSCORE I 26.2% ± 17.8%, STS-PROM 8.8% ± 7.4%) receiving ViV procedures from 2008 to 2014 were included for analysis. Data were prospectively gathered and retrospectively analyzed.
  
  
  RESULTS
  ViV was performed in aortic (72.0%, 54/75), mitral (22.7%, 17/75), tricuspid (2.7%, 2/75), and pulmonary (2.7%, 2/75) positions. THVs used were Edwards SAPIEN (XT)/SAPIEN3 (52.0%, 39/75), Medtronic Core Valve/Core Valve Evolut(R) (34.7%, 26/75), St Jude Portico (4.0%, 3/75), Boston Scientific Lotus (4.0%, 3/75), Jena Valve (2.7%, 2/75), and Medtronic Engager (2.7%, 2/75). Interval from index procedure to ViV was 9.3 ± 4.9 years. Access was transapical in 53.3% (40/75), transfemoral (transarterial or transvenous) in 42.7% (32/75), transaortic in 2.7% (2/75), and transjugular in 1.3% (1/75). ViV was successful in 97.3% (73/75) with 2 patients requiring sequential THV implantation for initial malpositioning. Overall immediate procedural (≤72 hours) and all-cause 30-day mortality were 2.7% (2/75) and 8.0% (6/75). Corresponding values after aortic ViV were 1.9% (1/54) and 5.6% (3/54). No periprocedural strokes or cases of coronary obstruction occurred. Paravalvular leakage was less than or equal to mild in all cases. After aortic ViV, gradients were max/mean 34.1 ± 14.2/20.1 ± 7.1 mm Hg and effective orifice area (EOA) was 1.5 ± 1.4 cm(2). Corresponding values after mitral ViV were gradients max/mean 14.2 ± 8.2/4.7 ± 3.1 mm Hg and EOA 2.4 ± 0.9 cm(2).
  
  
  CONCLUSIONS
  ViV can be performed in all anatomic positions with acceptable hemodynamic and clinical outcome in high-risk patients. Increasing importance of ViV can be anticipated considering growing use of surgical bioprostheses.
authors.affiliation: Department of Cardiovascular Surgery, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany. Electronic address: lconradi@uke.de.
authors.forename: Lenard
authors.initials: L
authors.lastname: Conradi
authors.affiliation: Department of Cardiovascular Surgery, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Miriam
authors.initials: M
authors.lastname: Silaschi
authors.affiliation: Department of Cardiology, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Moritz
authors.initials: M
authors.lastname: Seiffert
authors.affiliation: Department of Cardiology, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Edith
authors.initials: E
authors.lastname: Lubos
authors.affiliation: Department of Cardiology, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Stefan
authors.initials: S
authors.lastname: Blankenberg
authors.affiliation: Department of Cardiovascular Surgery, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Hermann
authors.initials: H
authors.lastname: Reichenspurner
authors.affiliation: Department of Cardiology, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Ulrich
authors.initials: U
authors.lastname: Schaefer
authors.affiliation: Department of Cardiovascular Surgery, University Heart Center Hamburg, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
authors.forename: Hendrik
authors.initials: H
authors.lastname: Treede
mesh_terms: D000368:Aged; D001705:Bioprosthesis / Q000009:adverse effects; D006328:Cardiac Catheterization; D005260:Female; D006349:Heart Valve Diseases / Q000601:surgery*; D006350:Heart Valve Prosthesis / Q000009:adverse effects; D019918:Heart Valve Prosthesis Implantation / Q000379:methods*; D006801:Humans; D008297:Male; D011475:Prosthesis Failure; D012189:Retrospective Studies; D016896:Treatment Outcome
keywords: structural valve deterioration; transcatheter; valve-in-valve