Intraprocedural valve-in-valve deployment for treatment of aortic regurgitation following transcatheter aortic valve replacement: An individualized approach.

BACKGROUND: Aortic regurgitation (AR) following transcatheter aortic valve replacement (TAVR) is usually due to paravalvular leak, is more common with self-expanding valves and is associated with adverse outcomes. Treatment of AR with a second valve (valve-in-valve) has been reported, however the mechanism of benefit is unclear. We hypothesized that location of the initial valve in relation to the aortic annulus should guide positioning of the second valve.

METHODS: We assessed the outcomes of valve-in-valve deployment for treatment of AR following implantation of self-expanding valves in a single-center TAVR registry. Location of the initial valves was defined as supra-annular, intra-annular or infra-annular according to the position of the device pericardial skirt relative to the annulus. Positioning of the second valve was selected according to the location of the initial valves.

RESULTS: Among 285 TAVR patients who received Corevalve or Evolut-R valves, 11 (3.8%) underwent valve-in-valve deployment due to AR. Position of initial valves was supra-annular in 6 cases (group-1), intra-annular in 3 cases (group-2) and infra-annular in 2 cases (group-3). In group-1, second valves were implanted 9 ± 4 mm lower than the initial valves. In group-2, second valves were implanted 7 ± 4 mm higher than the initial valves. In group-3, second valves were implanted 9 ± 1 mm higher than the initial valves. Valve-in-valve deployment reduced AR grade in all 3 groups.

CONCLUSIONS: Valve-in-valve deployment decreased AR grade during TAVR procedures. We suggest that positioning of the second valve should be guided by the location of the initial valve relative to the aortic annulus.