Matched Comparison of Self-Expanding Transcatheter Heart Valves for the Treatment of Failed Aortic Surgical Bioprosthesis

Valve type and post-dilation impact on transprosthetic gradients in patients undergoing transcatheter aortic valve-in-valve procedure

Aims

Valve-in-Valve transcatheter aortic valve replacement (ViV-TAVR) is an appealing treatment option for patients with degenerated aortic bioprosthetic valves. However, higher post-procedural transprosthetic gradients are more common after ViV-TAVR than after TAVR for native aortic valve stenosis. We sought to evaluate the impact of type of implanted valve and balloon post-dilation on echocardiographic results and mortality in ViV-TAVR patients.

Methods and results

One hundred and eleven consecutive patients were enrolled. A balloon-expandable valve, a self-expandable valve without balloon post-dilation, and a self-expandable valve with balloon post-dilation were performed in 35 (Group 1), 39 (Group 2), and 37 (Group 3) patients, respectively. All patients underwent comprehensive transthoracic echocardiography at baseline, discharge, and 6-12 months follow-up. Successful ViV-TAVR was performed in 110 patients (99%). Baseline transprosthetic gradients, left ventricular volumes, ejection fraction, and pulmonary artery systolic pressure were similar among groups. All groups experienced a significant reduction in post-procedural gradients at discharge and during the 6-12 months follow-up compared with baseline. At discharge, the lowest mean gradient was observed in Group 3 (12 ± 7 mmHg) compared with both Group 1 (20 ± 9 mmHg) and Group 2 (17 ± 8 mmHg, P = 0.001). This result was confirmed at 6-12 months follow-up (P = 0.012). Similar 5-year all-cause mortality was observed among groups (34%, 36%, 14%, respectively, P = 0.056).

Conclusion

In patients with failed surgical aortic prosthesis, ViV-TAVR is an effective treatment option associated with sustained improved haemodynamics regardless of transcatheter valve type and use of balloon post-dilation. However, self-expandable valves with balloon post-dilation showed lower transprosthetic gradients.

Contemporary review of the evolution of various treatment modalities for mitral regurgitation

INTRODUCTION

Mitral regurgitation is one of the most common forms of valvular heart diseases for which there have been several innovative treatment strategies that have developed over the last several decades. We describe the various treatment modalities that have been used for the last several decades. All articles in PubMed, Cochrane, and Embase were screened from inception to August 2024 for the following - 'Mitral valve regurgitation' 'Mitral valve repair' 'Mitral valve replacement' 'Robotic mitral surgery' 'Transcatheter mitral valve repair.'

AREAS COVERED

Mitral regurgitation (MR) is classified into primary and secondary MR. Causes of primary MR include degenerative disease, rheumatic heart disease, and infective endocarditis. Secondary MR is observed in the setting of left ventricle (LV) pathology, including ischemic or dilated cardiomyopathy. In secondary MR, annular dilation, papillary muscle displacement, tethering of chordae tendineae and/or mitral valve (MV) leaflets result in leaflet restriction and malcoaptation.

EXPERT OPINION

In this review, we discuss various modalities for the treatment of mitral regurgitation, as well as newer treatment options for MR including robotic MV repair and other minimally invasive procedures. Several ongoing randomized controlled trials in this topic will help shed more light and provide guidance to deliver the optimal care for our patients.

Comparison of two self-expanding transcatheter heart valves for degenerated surgical bioprostheses: the AVENGER multicentre registry

BACKGROUND

There is a lack of comparative data on transcatheter aortic valve implantation (TAVI) in degenerated surgical prostheses (valve-in-valve [ViV]).

AIMS

We sought to compare outcomes of using two self-expanding transcatheter heart valve (THV) systems for ViV.

METHODS

In this retrospective multicentre registry, we included consecutive patients undergoing transfemoral ViV using either the ACURATE neo/neo2 (ACURATE group) or the Evolut R/PRO/PRO+ (EVOLUT group). The primary outcome measure was technical success according to Valve Academic Research Consortium (VARC)-3. Secondary outcomes were 30-day all-cause mortality, device success (VARC-3), coronary obstruction (CO) requiring intervention, rates of severe prosthesis-patient mismatch (PPM), and aortic regurgitation (AR) ≥moderate. Comparisons were made after 1:1 propensity score matching.

RESULTS

The study cohort comprised 835 patients from 20 centres (ACURATE n=251; EVOLUT n=584). In the matched cohort (n=468), technical success (ACURATE 92.7% vs EVOLUT 88.9%; p=0.20) and device success (69.7% vs 73.9%; p=0.36) as well as 30-day mortality (2.8% vs 1.6%; p=0.392) were similar between the two groups. The mean gradients and rates of severe PPM, AR ≥moderate, or CO did not differ between the groups. Technical and device success were higher for the ACURATE platform among patients with a true inner diameter (ID) >19 mm, whereas a true ID ≤19 mm was associated with higher device success - but not technical success - among Evolut recipients.

CONCLUSIONS

ViV TAVI using either ACURATE or Evolut THVs showed similar procedural outcomes. However, a true ID >19 mm was associated with higher device success among ACURATE recipients, whereas in patients with a true ID ≤19 mm, device success was higher when using Evolut.

Guidelines for the Evaluation of Prosthetic Valve Function With Cardiovascular Imaging: A Report From the American Society of Echocardiography Developed in Collaboration With the Society for Cardiovascular Magnetic Resonance and the Society of Cardiovascular Computed Tomography

In patients with significant cardiac valvular disease, intervention with either valve repair or valve replacement may be inevitable. Although valve repair is frequently performed, especially for mitral and tricuspid regurgitation, valve replacement remains common, particularly in adults. Diagnostic methods are often needed to assess the function of the prosthesis. Echocardiography is the first-line method for noninvasive evaluation of prosthetic valve function. The transthoracic approach is complemented with two-dimensional and three-dimensional transesophageal echocardiography for further refinement of valve morphology and function when needed. More recently, advances in computed tomography and cardiac magnetic resonance have enhanced their roles in evaluating valvular heart disease. This document offers a review of the echocardiographic techniques used and provides recommendations and general guidelines for evaluation of prosthetic valve function on the basis of the scientific literature and consensus of a panel of experts. This guideline discusses the role of advanced imaging with transesophageal echocardiography, cardiac computed tomography, and cardiac magnetic resonance in evaluating prosthetic valve structure, function, and regurgitation. It replaces the 2009 American Society of Echocardiography guideline on prosthetic valves and complements the 2019 guideline on the evaluation of valvular regurgitation after percutaneous valve repair or replacement.

Impact of different in vitro models on functional performance of the self-expanding transcatheter heart valve

OBJECTIVES

Transcatheter heart valves (THVs) are investigated according to International Organization for Standardization requirements using in vitro heart simulators to evaluate hydrodynamic performance. In contrast to surgical valves, a THV's performance heavily depends on the configuration and shape of the aortic anulus. In International Organization for Standardization regulations, there is no detailed definition for the construction of a compartment in which a THV has to be tested. Therefore, the aim of this in vitro study was to compare different in vitro models for functional testing of THVs.

METHODS

Porcine aortic conduits (23-mm diameter) were implanted in Dacron prostheses and calcified with double-distilled water and calcification buffer at 37°C over 83 million cycles in a Hi-Cycler (durability testing) mimicking nearly 3 patient-years. Hydrodynamic testing of Evolut PRO 26 mm was performed within 3 models (plexiglass, native conduit and calcified conduit; all 23-mm diameter) at a frequency of 64 bpm and different stroke volumes (55-105 ml).

RESULTS

Calcified conduits showed significantly higher mean pressure gradients (MPG) and lower effective orifice areas (EOA) in comparison to native conduits (without THV; P < 0.001). EOA and MPG of Evolut PRO differed depending on the model tested. Calcified conduits resulted in the lowest EOA and highest MPG of the THV compared to plexiglass and the native conduit. Full expansion of the THV was least impaired in the native conduit, while lowest geometric orifice area, lowest minimal internal diameter and highest pin-wheeling index of Evolut PRO were seen in the calcified conduit.

CONCLUSIONS

Full expansion and functional performance of the Evolut PRO THV depends on the configuration of the testing compartment in an in vitro setting.

Cardiovascular Outcomes of Older versus Newer Generation Transcatheter Aortic Valve Replacement Recipients: A Systematic Review & Meta-analysis

Newer generation transcatheter heart valves (THV) are presumed to yield better clinical efficacy and postprocedural complication profile as compared to transcatheter aortic valve replacement (TAVR) using older generation THVs. The real impact of newer generation valves on TAVR outcomes is not well known. Studies comparing older and newer generation THVs were identified from online databases including PubMed, EMBASE, Cochrane, and ClinicalTrials.gov from inception until August 2020. The primary outcome of the study was to compare mortality. Secondary outcomes included cerebrovascular events, myocardial infarction, major vascular complications, major bleeding, acute kidney injury, paravalvular leak, and post-procedural pacemaker implantation. Statistical analysis was performed using the Mantel-Haenszel random effect model with an odds ratio (OR), 95% confidence interval (CI), and p-value significance ≤0.05. A total of 14 studies were included with a combined patient population of 5697 patients (older generation n=1996; newer generation n=3701). Newer generation valves showed statistically significant results favoring lower major vascular complications (OR=2.05; 95% CI, 1.33-3.18; P = 0.00), major bleeding (OR=1.99; 95% CI, 1.35-2.93; P = 0.00), acute kidney injury (OR=1.71; 95% CI, 1.13-2.59; P = 0.01), paravalvular leak (OR=2.41; 95% CI, 1.11-5.28; P = 0.03) and mortality (OR=1.50; 95% CI, 1.10-2.06; P = 0.01) as compared to older generation valves. Cerebrovascular events, myocardial infarction, and pacemaker placement rates were found to be similar between older and newer generation valves. TAVR outcomes using newer generation valves are superior to those of older generation valves in terms of major vascular complications, acute kidney injury, paravalvular leak, and mortality.

Transcatheter aortic valve implantation for degenerated surgical aortic bioprosthesis: A systematic review

Background:

Transcatheter aortic valve in valve (Aviv) replacement has been shown to be an effective therapeutic option in patients with failed aortic bioprosthetic valves. This review intended to evaluate contemporary 1-year outcomes of Aviv in recent studies.

Methods:

A systematic review on outcomes of Aviv was performed using the best available evidence from studies obtained using a MEDLINE, Cochrane database, and SCOPUS search. Endpoints of interest were survival, coronary artery obstruction, prosthesis-patient mismatch (PPM), stroke, pacemaker implantation, and structural valve deterioration.

Results:

A total of 3339 patients from 23 studies were included. Mean age was 68–80 years, 20%–50% were female, and Society of Thoracic Surgeons score ranged from 5.7 to 31.1. Thirty-day all-cause mortality ranged from 2% to 8%, and 1-year all-cause mortality ranged from 8% to 33%. Coronary artery obstruction risk after Aviv ranged from 0.6% to 4%. One-year stroke ranged from 2% to 8%. Moderate-severe PPM occurred in 11%–58%, and pacemaker rate at 1 year ranged from 5% to 12%.

Conclusion:

Transcatheter aortic ViV has emerged as an effective therapeutic option to treat patients with failed bioprostheses. The acceptable complication rate and favorable 1-year outcomes make Aviv an appropriate alternative to redo surgical aortic valve replacement.

Allegra Transcatheter Heart Valve inside a Degenerated Sutureless Aortic Bioprosthesis

Transcatheter aortic valve-in-valve implantation (VIV) is increasingly being used to successfully treat degenerated surgical aortic valve bioprostheses (SAVs). The new self-expanding transcatheter heart valve Allegra, from New Valve Technology with its special implantation mechanism, has proven its safety and feasibility for patients with degenerated SAVs, but it has never been used in the latest-generation sutureless SAV. To the best of our knowledge, this is the first description of the successful VIV of the Allegra prosthesis into a degenerated sutureless SAV, and the procedure yielded an excellent postinterventional hemodynamic results.

Bovine pericardial versus porcine stented replacement mitral valves: early hemodynamic performance and clinical results of a randomized comparison of the Perimount and the Mosaic valves

Background

To compare the hemodynamic and clinical outcomes following mitral valve replacement with the Perimount valve with those of the Mosaic valve.

Methods

A total of 145 consecutive patients with rheumatic heart valve disease who underwent single bioprosthetic mitral valve replacement were randomized to receive either the Perimount (n=72) valve or the Mosaic bioprosthesis (n=73). The mean age of patients was 72.1 years (range, 58-89 years) with a sex distribution of 55.2% female and 44.8% male. Patients underwent follow up transthoracic echocardiography at 3 months and 1 year postoperatively. We compared demographics, preoperative clinical data, operative data, hemodynamic profiles, and clinical outcomes.

Results

The cross-clamp time was similar, with 50.7±15.3 minutes for the Perimount and 50.7±21.8 minutes for the Mosaic bioprosthesis. The total bypass time was also similar, with 91.3±25.7 minutes for the Perimount and 87.8±25.6 minutes for the Mosaic valve. The peak and mean pressure gradients were lower in the Perimount group for all valve sizes and the difference was statistically significant at 1 year. The effective orifice area (EOA) was slightly larger in the Perimount valve (1.98±0.21 vs. 1.89±0.71 cm², P=0.538) postoperatively, but there was no significant difference at 1 year. There were no differences in preoperative or postoperative left atrium diameter (LAD), left ventricular diastolic diameter (LVDD), left ventricular systolic diameter (LVSD), left ventricular ejection fraction (LVEF), pulmonary artery pressure (PAP). The mortality and major complications rate were similar between the two groups.

Conclusions

The Perimount prostheses is superior to the Mosaic prostheses after mitral valve replacement, achieving statistically significant lower gradients and larger EOA when compared on the basis of manufacturer-labeled valve sizes. Both valves appear to provide satisfactory clinical results.

Durability and Clinical Outcomes of Transcatheter Aortic Valve Replacement for Failed Surgical Bioprostheses

Background:

Valve-in-valve transcatheter aortic valve replacement (TAVR) is an option when a surgical valve demonstrates deterioration and dysfunction. This study reports 3-year results following valve-in-valve with self-expanding TAVR.

Methods:

The CoreValve US Expanded Use Study is a prospective, nonrandomized, single-arm study that evaluates safety and effectiveness of TAVR in extreme risk patients with symptomatic failed surgical biologic aortic valves. Study end points include all-cause mortality, need for valve reintervention, hemodynamic changes over time, and quality of life through 3 years. Patients were stratified by presence of preexisting surgical valve prosthesis-patient mismatch.

Results:

From March 2013 to May 2015, 226 patients deemed extreme risk (STS-PROM [Society of Thoracic Surgeons Predicted Risk of Mortality] 9.0±7%) had attempted valve-in-valve TAVR. Preexisting surgical valve prosthesis-patient mismatch was present in 47.2% of the cohort. At 3 years, all-cause mortality or major stroke was 28.6%, and 93% of patients were in New York Heart Association I or II heart failure. Valve performance was maintained over 3 years with low valve reintervention rates (4.4%), an improvement in effective orifice area over time and a 2.7% rate of severe structural valve deterioration. Preexisting severe prosthesis-patient mismatch was not associated with 3-year mortality but was associated with significantly less improvement in quality of life at 3-year follow-up ( P =0.01).

Conclusions:

Self-expanding TAVR in patients with failed surgical bioprostheses at extreme risk for surgery was associated with durable hemodynamics and excellent clinical outcomes. Preexisting surgical valve prosthesis-patient mismatch was not associated with mortality but did limit patient improvement in quality of life over 3-year follow-up.

Clinical Trial Registration:

URL: http://www.clinicaltrials.gov . Unique identifier: NCT01675440.

How to treat severe symptomatic structural valve deterioration of aortic surgical bioprosthesis: transcatheter valve-in-valve implantation or redo valve surgery?

The optimal management of aortic surgical bioprosthesis presenting with severe symptomatic structural valve deterioration is currently a matter of debate. Over the past 20 years, the number of implanted bioprostheses worldwide has been rapidly increasing at the expense of mechanical prostheses. A large proportion of patients, however, will require intervention for bioprosthesis structural valve deterioration. Current options for older patients who often have severe comorbidities include either transcatheter valve-in-valve (TVIV) implantation or redo valve surgery. The emergence of TVIV implantation, which is perceived to be less invasive than redo valve surgery, offers an effective alternative to surgery for these patients with proven safety and efficacy in high-risk patient groups including elderly and frail patients. A potential caveat to this strategy is that results of long-term follow-up after TVIV implantation are limited. Redo surgery is sometimes preferable, especially for young patients with a smaller-sized aortic bioprosthesis. With the emergence of TVIV implantation and the long experience of redo valve surgery, we currently have 2 complementary treatment modalities, allowing a tailor-made and patient-orientated intervention. In the heart team, the decision-making should be based on several factors including type of bioprosthesis failure, age, comorbidities, operative risk, anatomical factors, anticipated risks and benefits of each alternative, patient's choice and local experience. The aim of this review is to provide a framework for individualized optimal treatment strategies in patients with failed aortic surgical bioprosthesis.

Transcatheter aortic valve replacement in failed surgical valves

Aortic valve-in-valve is a less invasive alternative to surgical redo in the treatment of failed bioprosthetic valves. While only inoperable patients underwent the procedure before, operators currently offer it to those at lower risk and worldwide experience is in the thousands. Early mortality has diminished in recent analyses and improvements in symptoms and quality of life have been documented. Main considerations with aortic valve-in-valve include elevated postprocedural gradients, coronary obstruction and leaflet thrombosis. Risk factors for each of these adverse events have been described at length. Aortic valve-in-valve offers a safe and effective option in the management of failed bioprosthetic valves.

Valve-in-valve-in-valve: Balloon expandable transcatheter heart valve in failing self-expandable transcatheter heart valve in deteriorated surgical bioprosthesis

Valve-in-valve (ViV) procedures for failing bioprostheses carry a certain risk for device malfunction. We herein report a case of a failing Evolut R in a deteriorated Mitroflow, treated with a Sapien 3. An 81 year old female patient received surgical aortic valve replacement and was treated by ViV due to deterioration. Three years later, echocardiography revealed a pressure gradient of peak/mean 105/63 mmHg. Subsequently, a second ViV procedure with initial intentional rupture of the bioprosthetic stent was performed. Immediate stent recoil of the Evolut R prompted implantation of a Sapien 3. In 30-day follow-up, mean pressure gradient of 30 mmHg and nearly complete symptom relief was documented. Fracture of a surgical bioprosthetic stent is feasible in a ViV configuration. Supra-annular placement of a balloon-expandable THV as ViV-in-valve is feasible with suboptimal hemodynamic results in this case. Risk of re-do surgery should be weighted against anticipated hemodynamic and clinical results.

Comparison of Early and Long-Term Outcomes After Transcatheter Aortic Valve Implantation in Patients with New York Heart Association Functional Class IV to those in Class III and Less

Our aim was to investigate the impact of a baseline New York Heart Association (NYHA) class IV on clinical outcomes of a large real-world population who underwent transcatheter aortic valve implantation (TAVI). The primary end points were all-cause mortality, cardiovascular mortality, and re-hospitalization, evaluated at the longest available follow-up and by means of a 3-month landmark analysis. The secondary end points were: change in NYHA class, left ventricular ejection fraction, pulmonary pressure and mitral regurgitation. Out of 2,467 patients, 271 (11%) had a NYHA functional class IV at the admission. The latter had higher Society of Thoracic Surgeons (STS) score (9.2% vs 5.5%; p < 0.001) compared to NYHA ≤ III patients, owing to more comorbidities (prior myocardial infarction, severe long-term kidney disease, atrial fibrillation, left ventricular dysfunction, significant mitral regurgitation, pulmonary hypertension). Device success was similar between the two groups (93.7% vs 94.5%; p = 0.583). At a median follow-up of 15 months (interquartile range 4 to 36 months) a lower freedom from primary end points was observed among NYHA IV versus NYHA ≤ III group (survival from all-cause death: 52% vs 58.4%; p = 0.002; survival from cardiovascular death: 72.5% vs 76.5%; p = 0.091; freedom from re-hospitalization: 81.5% vs 85.4%; p = 0.038). However, after adjustment for baseline imbalance, NYHA IV did not influence the relative risk of long-term primary end points. A 3-month landmark analysis showed that NYHA IV independently predicted 3-month all-cause and cardiovascular mortality (hazard ratio: 1.77; 95% CI [1.10 to 2.83]; p = 0.018 and hazard ratio: 1.64; 95% CI [1.03 to 2.59]; p = 0.036, respectively). Instead, after 3-month follow-up NYHA IV did not affect the risk of primary end points. A significant improvement of the secondary end points was noted in both NYHA IV and NYHA ≤≤ III groups. In conclusion, the presence of NYHA class IV in TAVI candidates was associated to a significant increased risk of mortality within 3 months. Patients with baseline NYHA IV who survived at 3 months had a long-term outcome comparable to that of other subjects. Left ventricular systolic function, pulmonary pressure, and mitral insufficiency significantly improved after TAVI regardless of baseline NYHA class IV.

Outcomes of Self-Expanding vs. Balloon-Expandable Transcatheter Heart Valves for the Treatment of Degenerated Aortic Surgical Bioprostheses - A Propensity Score-Matched Comparison

BACKGROUND

Transcatheter aortic valve-in-valve (VIV) replacement within failed bioprosthetic surgical aortic valves is a feasible therapeutic option. However, data comparing the hemodynamic and clinical outcomes of VIV replacement with supra-annular self-expanding and balloon-expandable transcatheter heart valves (THV) are limited.

METHODS AND RESULTS

Outcomes of 40 and 95 patients treated with supra-annular self-expanding and balloon-expandable THV, respectively, were compared after propensity score matching, which yielded 37 pairs of patients with similar baseline characteristics. Hemodynamic and clinical outcomes were analyzed. Postprocedural mean gradient was significantly lower in the self-expanding THV group than in the balloon-expandable THV group (12.1±6.1 mmHg vs. 19.0±7.3 mmHg, P<0.001). The incidence of at least mild postprocedural aortic regurgitation (AR) was comparable between the self-expanding and balloon-expandable THV groups (21.6% vs. 10.8%, P=0.39). In the self-expanding THV group, the new-generation THV showed a trend towards a lower incidence of at least mild AR compared with the early-generation THV (12.5% vs. 38.5%, P=0.07). A similar trend was observed in the balloon-expandable THV group (4.2% vs. 23.1%, P=0.08). There was no significant difference between the self-expanding and balloon-expandable THV groups in the cumulative 2-year all-cause mortality rates (22.4% vs. 43.4%, log-rank P=0.26).

CONCLUSIONS

The supra-annular self-expanding THV was associated with a lower postprocedural mean gradient compared with balloon-expandable THV in patients undergoing aortic VIV replacement.

Transcatheter aortic valve replacement: The year in review 2017

This article is a continuation of our previously published annual reviews of transcatheter aortic valve replacement (TAVR). In 2017, TAVR further established a foothold in the management of intermediate risk patients with the publication of SURTAVI trial. Randomized trials also addressed the use of cerebral protection during TAVR and single versus dual antiplatelet therapy after TAVR. Newer generation valve systems continued to be studied for their efficacy and safety. This paper summarizes the major studies published in 2017.

Neo Left Main Channel Creation Using Double Stenting Alongside a Sapien 3 Aortic Valve Bioprosthesis for Left Main Coronary Obstruction Following Valve-in-Valve Transcatheter Aortic Valve Replacement: A Case Report With Review of Literature

Transcatheter aortic valve replacement in the setting of failed surgical bioprosthesis (valve-in-valve) is a valuable option for patients with bioprosthetic aortic stenosis or regurgitation who are deemed high risk for repeat open heart surgery. Although the procedure is successful with proper preprocedural assessment, instances of left main (LM) coronary artery ostium obstruction have been documented. We present a case of LM coronary obstruction in the immediate postoperative period following implantation of a 20-mm Edwards Sapien 3 valve inside the degenerated 21-mm Mitroflow bioprosthesis stenosis, which was treated with double stenting alongside the Edwards Sapien 3 valve creating a channel (“neo left main”) that extended from mid-LM to the upper margin of the Edwards Sapien 3 valve. Although valve-in-valve in a Mitroflow degenerated bioprosthesis is a relatively safe procedure, 2 or more stents may be necessary to scaffold a channel to the coronary arteries between Edwards Sapien 3 prosthesis and aorta in the event of a coronary obstruction.

Transcatheter Aortic Valve Implantation for Degenerated 19-mm Aortic Bioprosthetic Valve

BACKGROUND

The valve-in-valve procedure, in which a transcatheter heart valve (THV) is implanted over a prosthetic valve, has been shown to be safe and therapeutically effective, depending on the size of the replacement valve.

METHODS AND RESULTS

We report 3 cases of successful valve-in-valve procedure to replace a degenerated 19-mm stented prosthetic aortic valve. Balloon-expanding THVs were implanted: 20-mm in the 1st case and 23-mm in the next 2. Aortic stenosis was almost completely resolved in all patients, who recovered promptly and without cardiac adverse events.

CONCLUSIONS

Using the valve-in-valve procedure for a 19-mm degenerated bioprosthesis was feasible and safe.