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Van Linden A, Blumenstein J, Walther T, et al. (2013) . Clinical research in cardiology : official journal of the German Cardiac Society 102:241-243
Transcatheter aortic valve implantation (T-AVI) has emerged as a standardized routine procedure to treat elderly high-risk patients suffering from severe aortic valve stenosis and the number of worldwide implantations is increasing [2-4]. The two mostly common used approaches are transapical (TA)  and transfemoral (TF)  using the Edwards SAPIEN (XT)™ and the Medtronic CoreValve® prostheses. Meanwhile several “second generation” T-AVI prostheses have entered the market either for TA or TF approach. Two CE-mark approved TA devices are the Symetis ACURATE TA™ and the JenaValve™. Both are porcine valves on a self-expandable nitinol stent with unique stepwise implantation features [7, 8]. After gaining more experience with T-AVI in native stenotic valves, the idea of implanting a T-AVI prosthesis in degenerated xenografts has been developed and also emerged to an alternative treatment option [9-15]. Furthermore, immediately valve-in-valve implantation of a second T-AVI prosthesis in a failed T-AVI prosthesis has turned out to be a rescue option to avoid sternotomy and conversion to conventional aortic valve replacement .Our case report describes the first valve-in-valve implantations of an Edwards SAPIEN XT™ prosthesis in second generation T-AVI prostheses using the TA approach . In both cases a severe aortic regurgitation >2+ indicated immediate treatment. Re-ballooning did not reduce the regurgitation and the decision for rescue valve-in-valve implantation was made. Both procedures could be performed successfully without any complications. Both patients were alive at 1-year follow up with NYHA functional class I and echocardiography showed excellent hemodynamic function of the prostheses (mean gradients ≤10 mmHg).In summary, valve-in-valve implantation of a SAPIEN (XT)™ prosthesis inside an ACURATE TA™ or a JenaValve™ prosthesis seems to be an adequate rescue option for severe aortic regurgitation after implantation of these second generation T-AVI prostheses.
This letter reports 2 complicated transapical TAVI cases using new-generation self-expanding prostheses. In both cases, malpositioning of the prosthesis caused severe paraprosthetic aortic regurgitation, requiring a rescue valve-in-valve implantation using a SAPIEN transcatheter valve, with a good final result and a favorable one-year outcome. This report may invite 2 comments.