Use of Transcatheter Heart Valves for a Valve-In-Valve Implantation in Patients With Degenerated Aortic Bioprosthesis: Technical Considerations and Results

Study Questions:

What is the current experience with transcatheter aortic valve implantation in the treatment of degenerated biologic aortic valve prostheses and investigation of factors that can influence the outcome?


From February 2009 to October 2011, 278 patients underwent transcatheter aortic valve implantation, of whom 23 underwent a valve-in-valve procedure with the Edwards Sapien valve to treat a failing bioprostheses in the aortic position. Eight of these valves were stentless bioprostheses. Aortography and transesophageal echocardiography (TEE) assessment were used to determine the correct placement and function of the Sapien valve and patency of the coronary arteries. TEE assessment was used to identify and grade paravalvular leak (mild, moderate, and severe). Thirteen patients had valve failure resulting predominantly from stenosis, and the remaining resulting from regurgitation.


Mean age was 76.9 ± 14.4 years. The mean logistic EuroSCORE was 31.8% ± 20.3%, and the Society of Thoracic Surgeons score was 7.6% ± 5.4%. All patients were New York Heart Association class III or IV. The majority of the operations (21/23) were performed via the transapical route. Procedural success was 100%, although one patient with a degenerated homograft needed immediate placement of a second valve because of low placement of the first. The reduction in the mean gradient was 31.2 ± 17.06 mm Hg to 9.13 ± 4.9 mm Hg. In those patients with predominant aortic regurgitation (9/23), reduction in aortic regurgitation was achieved in all. The median length of stay was 11.7 days (range, 3-44 days). In-hospital and/or 30-day mortality was 0%.


The authors concluded that valve-in-valve is a safe and feasible alternative to treat high-risk patients with failing aortic bioprostheses.


The current case series suggests that valve-in-valve may be a useful alternative in selected patients who are at high risk for undergoing an open surgical procedure. Case selection is of critical importance and should be decided by a multidisciplinary team. Although the early results reveal improvement in hemodynamics and amelioration of symptoms, longer follow-up with a larger cohort of patients is needed to validate these preliminary results and confirm efficacy.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Interventions and Imaging, Echocardiography/Ultrasound

Keywords: Heart Valve Prosthesis Implantation, Echocardiography, Transesophageal

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