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Technical update on transcatheter valve-in-valve therapy: 5 devices, 4 anatomic positions
Lenard Conradi, Miriam Silaschi, Moritz Seiffert, Edith Lubos, Stefan Blankenberg, Hermann Reichenspurner, Ulrich Schäfer, Hendrik Treede.
University Heart Center Hamburg, Hamburg, Germany.

OBJECTIVE: Transcatheter valve-in-valve implantation (ViV) is emerging as a novel option for treatment of deteriorated bioprostheses. We report our cumulative experience using five different types of transcatheter heart valves (THV) in all four anatomic positions with an emphasis on technical considerations.
METHODS: 60 consecutive patients (74.4±13.6 years, 53.3% male (32/60), logEuroSCORE I 27.9±19.9%, STS Score 9.2±7.6%) receiving ViV procedures from 2008 through 2014 at our center were included for analysis. Data were prospectively gathered and retrospectively analyzed.
RESULTS: ViV implantation was performed in aortic (n=42), mitral (n=14), tricuspid (n=2) and pulmonary (n=2) positions. THV used were Edwards Sapien / Sapien XT / Sapien 3 (n=36), Medtronic CoreValve / CoreValve Evolut (n=18), St. Jude Portico (n=2), JenaValve (n=2) and Medtronic Engager (n=2). Mean interval from index procedure to ViV was 8.7±5.5 years. Access was transapical in 60.0% (n=36) and endovascular in 40% (n=24). ViV was successful in 96.7% (58/60), in two cases of aortic ViV distal embolization of THV required implantation of a sequential valve. Overall all-cause 30-day mortality was 8.3% (5/60) and it was 4.8% (2/42) in the aortic position. No periprocedural strokes were observed. Paravalvular leakage was ≤ grade I in all cases. After aortic ViV, resultant gradients were max/mean 34.2±11.6 / 17.9±6.6 mmHg and effective orifice area (EOA) was 1.4±0.3 cm2. Corresponding values after mitral ViV were gradient max/mean 16.5±6.0 / 7.0±3.4 mmHg and EOA 2.1±0.5 cm2.
CONCLUSIONS: ViV can be performed in all anatomic positions with acceptable hemodynamic and clinical outcome in this high-risk patient population. Different types of THV are needed to provide optimal care. Meticulous planning, considering aortic root anatomy as well as technical specifications of deteriorated surgical valves is mandatory. In the light of increasing use of surgical bioprostheses, growing importance of ViV can be anticipated for the future.

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