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Aims : The valve-in-valve (ViV) procedure has become a valuable alternative for the treatment of failed surgical bioprostheses (BP) in high-risk patients. However, in small BP, the clinical outcomes have been suboptimal due to high post-procedural gradients. We aimed to examine the effect of size and position of the self-expanding transcatheter heart valve (THV) CoreValve on the haemodynamics of ViV within small BP. Methods and results : Sizes 23 and 26 mm of the CoreValve were implanted in sizes 19 and 21 mm of three BP models: Trifecta, Mitroflow and Epic Supra. The THV was tested in three positions -normal (manufacturer recommendation), low (4 mm below normal) and high (4 mm above normal)- using a pulse duplicator. Haemodynamics were assessed by Doppler echocardiography and flowmeter, and GOA with a high-speed camera. Higher implantation was associated with lower residual gradients (normal position: -9%, high: -25% versus low). High position was, however, associated with increased risk of regurgitation in the Mitroflow and embolisation in the Epic Supra. Using a 26 mm THV instead of a 23 mm was associated with larger EOAs in the Trifecta, smaller in the Mitroflow, and increased risk of embolisation in the Epic Supra. Conclusions : Supra-annular positioning of the CoreValve THV is associated with improved post-ViV haemodynamics in small surgical BP. The haemodynamic outcomes are highly dependent on the model and size of surgical BP.

Aims : The valve-in-valve (ViV) procedure has become a valuable alternative for the treatment of failed surgical bioprostheses (BP) in high-risk patients. However, in small BP, the clinical outcomes have been suboptimal due to high post-procedural gradients. We aimed to examine the effect of size and position of the self-expanding transcatheter heart valve (THV) CoreValve on the haemodynamics of ViV within small BP. Methods and results : Sizes 23 and 26 mm of the CoreValve were implanted in sizes 19 and 21 mm of three BP models: Trifecta, Mitroflow and Epic Supra. The THV was tested in three positions -normal (manufacturer recommendation), low (4 mm below normal) and high (4 mm above normal)- using a pulse duplicator. Haemodynamics were assessed by Doppler echocardiography and flowmeter, and GOA with a high-speed camera. Higher implantation was associated with lower residual gradients (normal position: -9%, high: -25% versus low). High position was, however, associated with increased risk of regurgitation in the Mitroflow and embolisation in the Epic Supra. Using a 26 mm THV instead of a 23 mm was associated with larger EOAs in the Trifecta, smaller in the Mitroflow, and increased risk of embolisation in the Epic Supra. Conclusions : Supra-annular positioning of the CoreValve THV is associated with improved post-ViV haemodynamics in small surgical BP. The haemodynamic outcomes are highly dependent on the model and size of surgical BP.