Background-The majority of prosthetic heart valves currently implanted are tissue valves that can be expected to degenerate with time and eventually fail. Repeat cardiac surgery to replace these valves is associated with significant morbidity and mortality. Transcatheter heart valve implantation within a failed bioprosthesis, a "valve-in-valve" procedure, may offer a less invasive alternative. Methods and Results-Valve-in-valve implantations were performed in 24 high-risk patients. Failed valves were aortic (nϭ10), mitral (nϭ7), pulmonary (nϭ6), or tricuspid (nϭ1) bioprostheses. Implantation was successful with immediate restoration of satisfactory valve function in all but 1 patient. No patient had more than mild regurgitation after implantation. No patients died during the procedure. Thirty-day mortality was 4.2%. Mortality was related primarily to learning-curve issues early in this high-risk experience. At baseline, 88% of patients were in New York Heart Association functional class III or IV; at the last follow-up, 88% of patients were in class I or II. At a median follow-up of 135 days (interquartile range, 46 to 254 days) and a maximum follow-up of 1045 days, 91.7% of patients remained alive with satisfactory valve function. Conclusions-Transcatheter valve-in-valve implantation is a reproducible option for the management of bioprosthetic valve failure. Aortic, pulmonary, mitral, and tricuspid tissue valves were amenable to this approach. This finding may have important implications with regard to valve replacement in high-risk patients.

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Background-Patients with severe aortic stenosis and reduced left ventricular ejection fraction (LVEF) have a poor prognosis with conservative therapy but a high operative mortality when treated surgically. Recently, transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement (SAVR) for patients considered at high or prohibitive operative risk. The objective of this study was to compare TAVI and SAVR with respect to postoperative recovery of LVEF in patients with severe aortic stenosis and reduced LV systolic function. Methods and Results-Echocardiographic data were prospectively collected before and after the procedure in 200 patients undergoing SAVR and 83 patients undergoing TAVI for severe aortic stenosis (aortic valve area Յ1 cm

TAVI is associated with a high rate of silent cerebral ischemic lesions as evaluated by DW-MRI, with no differences between the TF and TA approaches. These results provide important novel insight into the mechanisms of CE associated with TAVI and support the need for further research to both reduce the incidence of CE during these procedures and better determine their clinical relevance.

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Aortic stenosis is a common disorder. Aortic valve replacement is indicated in symptomatic patients with severe aortic stenosis, as the prognosis of untreated patients is poor. Nevertheless, many patients pose a prohibitively high surgical risk and are not candidates for surgical valve replacement. Transcatheter aortic valve implantation (TAVI) is a novel method to treat selected high-risk patients with aortic stenosis. Patient screening and anatomic measurements of the aortic root are of great importance to ensure procedural success and appropriate patient selection. Multidetector computed tomography (CT) is playing an increasingly important role in patient screening protocols before TAVI, provides detailed anatomic assessment of the aortic root and valve annulus, assesses the suitability of iliofemoral access, and determines appropriate coaxial angles to optimize the valve implantation procedure. Additionally, CT is providing a greater understanding of medium-term valve durability and integrity. This review outlines an evolving role for CT angiography in support of a TAVI program and describe step by step how CT can be used to enhance the procedure and provide a practical guide for the utilization of CT angiography in support of a transcatheter aortic valve program.

When bioprosthetic cardiac valves fail, reoperative valve replacement carries a higher risk of morbidity and mortality compared with initial valve replacement. Transcatheter heart valve implantation may be a viable alternative to surgical aortic valve replacement for high-risk patients with native aortic stenosis, and valve-in-valve (V-in-V) implantation has been successfully performed for failed surgical bioprostheses in the aortic, mitral, pulmonic, and tricuspid positions. Despite some core similarities to transcatheter therapy of native valve disease, V-in-V therapy poses unique clinical and anatomic challenges. In this paper, we review the challenges, selection criteria, techniques, and outcomes of V-in-V implantation.

The incidence of CeV events is highest within 24 h of TAVI, but this risk may remain elevated for up to 2 months. A prior history of cerebrovascular disease is an independent predictor. This may have implications for patient selection and antithrombotic strategies.