Images and Case Reports in Interventional Cardiology Percutaneous Aortic “Valve in Valve” Implantation for Severe Aortic Regurgitation in a Degenerated Bioprosthesis Ulrike Krumsdorf, MD; Raffi Bekeredjian, MD; Grigorios Korosoglou, MD; Joerg Kreuzer, MD; Benjamin J. Rieck; Klaus Kallenbach, MD; Hugo A. Katus, MD; Wolfgang Rottbauer, MD I n recent years, transcatheter aortic valve implantation has become an emerging alternative for high-risk patients with severe aortic stenosis. Midterm outcomes compare favorably with conventional open heart surgery in selected patients. A promising new indication in this technology could be the interventional treatment of degenerated bioprostheses. Here, we report about a “valve in valve” implantation of the CoreValve prosthesis (Medtronic, Inc; Minneapolis, Minn) in a degenerative, Epic stented biological prosthesis (St Jude Medical; St Paul, Minn) in a patient with acute aortic regurgitation. A male patient aged 79 years with previous surgical valve replacement 5 years ago was admitted to the hospital with acute dyspnea (New York Heart Association class III to IV). At physical examination, a diastolic murmur (grade 4) and a blood pressure of 130/50 mm Hg were noted. Transthoracic and transesophageal echocardiography showed degeneration of the 23-mm Epic stented bioprosthesis with severe central aortic regurgitation due to cusp prolapse (online-only Data Supplemental Videos I and II). Further- more, echocardiographic measurements are summarized in the Table. Coronary angiogram revealed coronary artery disease without significant stenoses. Aortic root angiogram (supplemen- tal Video III) confirmed severe aortic regurgitation (grade III to IV) in concordance with the findings on echocardiography. Because of previous cardiac surgery and comorbidities, periop- erative risk was regarded as significantly increased, with a calculated logistic EuroSCORE of 23% and Society Thoracic Surgeons risk score of 9.5%. Thus, a percutaneous approach was considered as a bail out procedure. Computed tomographic scan of the great arteries was performed (Figure 1) to evaluate the patient for percutaneous valve replacement. Having informed consent and approval by the institutional review board, the procedure was performed under local anesthesia. A third-generation 26-mm CoreValve prosthesis was successfully implanted through the right fem- oral artery (supplemental Videos IV through VI). Final aortic root angiogram showed no aortic regurgitation. The end-di- astolic pressure in the left ventricle immediately decreased from 50 to 20 mm Hg (Figure 2). No postprocedural compli- cations were noted, and the patient was discharged 6 days after the procedure with significantly improved symptoms (New York Heart Association class I). At 6 months follow-up, trans- esophageal echocardiography confirmed adequate position of the prosthesis with the absence of residual regurgitation (supple- mental Videos VII and VIII). The patient remained free of symptoms with functional New York Heart Association class I. ECG-gated, 256-slice cardiac computed tomography demon- strated stable valve-in-valve prostheses with completely ex- panded circular frame geometry (Figure 1). Presumably because of extended use of bioprosthetic valve replacement and ageing of the population, the number of degenerative bioprostheses will increase in the future. More comorbidities with increasing age may reduce eligibility for a second cardiac surgery in many patients. As already shown in several studies, transcatheter valve implantation has been proven to be feasible for severe aortic stenosis using either Table. Echocardiographic Measurements Pre-TAVI 6 Months Post-TAVI Aortic regurgitation Grade III 0 Pressure half-time, ms 194 — Jet width/LVOT width, % 80 0 Jet CSA/LVOT CSA, % 78 0 Regurgitant fraction, % 77 0  AO peak, mm Hg 19 8 Mitral regurgitation Grade I Grade I Systolic PAP, mm Hg 55 25 LVESD, mm 45 36 LVEDD, mm 60 53 LVEF, % 50 60  AO indicates transaortic gradient; CSA, cross-sectional area; LVEDD, left ventricle end-diastolic diameter; LVEF, left ventricular ejection fraction; LVESD, left ventricle end-systolic diameter; LVOT, left ventricular outflow tract; PAP, pulmonary artery pressure; TAVI, transcatheter aortic valve implantation. Received November 4, 2009; accepted April 6, 2010. From the Department of Cardiology (U.K., R.B., G.K., H.A.K., W.R.), University Hospital Heidelberg, Heidelberg, Germany; Department of Cardiology (J.K.), Limburg Hospital, Limburg, Germany; Department of Cardiac and Thoracic Surgery (K.K.), University Hospital Heidelberg, Heidelberg, Germany; and Medtronic, Inc (B.J.R.), Minneapolis, Minn. The online Data Supplement is available at http://circinterventions.ahajournals.org/cgi/content/full/3/3/e6/DC1. Correspondence to Ulrike Krumsdorf, MD, Department of Cardiology, University Hospital Heidelberg, Im Neuenheimer Feld 410, 69120 Heidelberg, Germany. E-mail Ulrike.Krumsdorf@med.uni-heidelberg.de (Circ Cardiovasc Interv. 2010;3:e6-e7.) © 2010 American Heart Association, Inc. Circ Cardiovasc Interv is available at http://circinterventions.ahajournals.org DOI: 10.1161/CIRCINTERVENTIONS.109.920181 e6