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Aims: We aimed to assess the impact of implant depth on hydrodynamic function following valve-in-valve (VIV) intervention using the ALLEGRA transcatheter heart valve (THV) in three different surgical valve designs., Methods and Results: Multiple implantation depths (+2 mm, -2 mm and -6 mm) were tested using a 23 mm ALLEGRA THV for VIV intervention in 19 mm, 21 mm, 23 mm, and 25 mm Epic, Mitroflow and Magna Ease bioprosthetic valves. Multimodality imaging and hydrodynamic evaluation was performed at each implantation depth. The 23 mm ALLEGRA valve had gradients <20 mmHg in the Mitroflow and Epic valves sized ≥21 mm, and in all sizes of the Magna Ease valve. Gradients did not increase significantly at lower implantation depths. The 19 mm Epic (+2 mm: 20.1±0.6 mmHg, -2 mm: 18.8±0.5 mmHg, -6 mm: 22.8±0.3 mmHg) and 19 mm Mitroflow (+2 mm: 24.1±0.2 mmHg, -2 mm: 31.5±0.3 mmHg, -6 mm: 25.6±0.2 mmHg) valves had elevated mean gradients. In larger sized surgical valves (≥23 mm) the regurgitant fraction was higher at low implantation depths. Pinwheeling was significantly worse in the smaller sized (≤21 mm) surgical valves and also at low (<-2 mm) implantation depth., Conclusions: The 23 mm ALLEGRA valve had favourable (<20 mmHg) gradients in all surgical valves sized ≥21 mm, even when the THV was implanted low. In 19 mm sized Mitroflow and Epic valves, gradients were elevated (>20 mmHg). While there was no major difference in mean transvalvular gradients, leaflet pinwheeling was worse at lower implantation depths.

Aims: We aimed to assess the impact of implant depth on hydrodynamic function following valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) using the ACURATE neo transcatheter heart valve (THV) through an ex vivo bench study., Methods and Results: Multiple implantation depths were tested at incremental depths of 2 mm using a small size ACURATE neo valve for VIV TAVR in 19 mm, 21 mm, 23 mm, and 25 mm Mitroflow bioprosthetic valves. Multimodality imaging and hydrodynamic evaluation was performed at each implantation depth. A low implantation was associated with higher transvalvular gradients. The highest transvalvular gradient was observed at -10 mm depth for 19 mm (40.0±0.5 mmHg), -8 mm for 21 mm (15.3±0.2 mmHg), -6 mm for 23 mm (14.7±0.3 mmHg) and -8 mm for 25 mm (8.4±0.2 mmHg) surgical valves. The lowest transvalvular gradient was observed at 0 mm depth for the 19 mm (14.9±0.2 mmHg)/21 mm (7.2±0.1 mmHg), and +2 mm depth for the 23 mm (5.7±0.1 mmHg)/25 mm (5.8±0.1 mmHg) surgical valves. At low implantation depth, there was worse leaflet pin-wheeling and also evidence of interaction of THV leaflets with those of the surgical valve that impaired leaflet coaptation, resulting in a high regurgitant fraction (42.5% in the 21 mm and 83.3% in the 23 mm surgical valve at -10 mm depths)., Conclusions: A high implant is desirable to facilitate favourable hydrodynamic function when performing VIV TAVR using the ACURATE neo THV for Mitroflow aortic bioprostheses sized ±25 mm. In a 19 mm Mitroflow valve, positioning the upper crown of the ACURATE neo THV above the posts of the surgical valve is desirable to facilitate favourable transvalvular gradients. Low implantation results in higher transvalvular gradients and worse pin-wheeling, and THV leaflet dysfunction can be severe due to interaction with the surgical valve.

Aims: The aim of this study was to provide contemporary outcome data for patients with de novo coronary disease and Medina 1,1,1 lesions who were treated with a culotte two-stent technique, and to compare the performance of two modern-generation drug-eluting stent (DES) platforms, the 3-connector XIENCE and the 2-connector SYNERGY., Methods and Results: Patients with Medina 1,1,1 bifurcation lesions who had disease that was amenable to culotte stenting were randomised 1:1 to treatment with XIENCE or SYNERGY DES. A total of 170 patients were included. Technical success and final kissing balloon inflation occurred in >96% of cases. Major adverse cardiovascular or cerebrovascular events (MACCE: a composite of death, myocardial infarction [MI], cerebrovascular accident [CVA] and target vessel revascularisation [TVR]) occurred in 5.9% of patients by nine months. The primary endpoint was a composite of death, MI, CVA, target vessel failure (TVF), stent thrombosis and binary angiographic restenosis. At nine months, the primary endpoint occurred in 19% of XIENCE patients and 16% of SYNERGY patients (p=0.003 for non-inferiority for platform performance)., Conclusions: MACCE rates for culotte stenting using contemporary everolimus-eluting DES are low at nine months. The XIENCE and SYNERGY stents demonstrated comparable performance for the primary endpoint.