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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Transcatheter aortic valve implantation &#40;TAVI&#41; has become an alternative to surgical aortic valve replacement &#40;SAVR&#41; in high-risk patients with severe aortic stenosis &#40;AS&#41;&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> The complications associated with this procedure are different from those related to SAVR&#46; This article describes the case of a patient who suffered dislocation of a Medtronic CoreValve<span class="elsevierStyleSup">&#174;</span> during initial TAVI treatment&#46; Eventually&#44; after several months of moderate improvement&#44; she needed another intervention&#44; which was performed with a St&#46; Jude Portico<span class="elsevierStyleSup">&#174;</span> repositionable self-expanding transcatheter aortic valve&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">The authors report a case of an 86-year-old woman presenting with New York Heart Association &#40;NYHA&#41; class II symptoms and severe AS &#40;maximum and mean transvalvular gradients of 199 and 75 mmHg&#44; respectively&#59; aortic valve area 0&#46;7 cm<span class="elsevierStyleSup">2</span>&#41;&#46; She had preserved left ventricular systolic function and non-significant coronary artery disease&#44; and was rejected for SAVR due to advanced age&#44; low weight and extreme frailty &#40;logistic EuroSCORE I and II 19&#46;79&#37; and 4&#46;22&#37;&#44; respectively&#59; Society of Thoracic Surgeons score 3&#46;7&#37;&#41;&#46;</p><p id="par0015" class="elsevierStylePara elsevierViewall">The patient underwent a first TAVI in 2012&#44; through angiography-guided femoral access&#46; Valvuloplasty was performed with a 20 mm NuMED Nucleus balloon followed by implantation of a 26 mm CoreValve<span class="elsevierStyleSup">&#174;</span>&#46; During this procedure&#44; the valve became dislodged and migrated to the ascending aorta due to excessive tension on the first-generation delivery catheter making it uncontrollable during fine manipulation of the valve release&#46; A snare technique was used to reposition the prosthesis upward&#44; without affecting the coronaries&#46; Given the fact that valvuloplasty had been performed and the percutaneous aortic valve was of the first generation and not repositionable&#44; it was decided to suspend the procedure and postpone any possible second intervention&#46; The patient&#39;s AS became moderate&#44; with maximum and mean gradients decreasing to 67 and 35 mmHg&#44; respectively&#44; and she improved to NYHA class I&#46; No neurologic&#44; aortic or peripheral vascular complications occurred&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">One year later her AS worsened &#40;maximum and mean transvalvular gradients of 101 and 61 mmHg&#44; respectively&#59; aortic valve area 0&#46;8 cm<span class="elsevierStyleSup">2</span>&#41; and&#44; in 2014&#44; she was hospitalized for congestive heart failure&#46; The heart team decided on a new TAVI with a repositionable system as the first-line approach&#44; and a balloon-expandable TAVI as a second-line solution&#46; Percutaneous coronary intervention &#40;due to progression of coronary artery disease&#41; was followed by transfemoral TAVI &#40;valve-in-valve&#41; under three-dimensional transesophageal echocardiographic guidance &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; The CoreValve<span class="elsevierStyleSup">&#174;</span> was immobilized with a 15 mm snare loop by a radial approach&#46; After valvuloplasty with a 20 mm Nucleus balloon&#44; a 25 mm Portico<span class="elsevierStyleSup">&#174;</span> valve was implanted&#46; Post-dilation was performed for underexpansion&#46; The patient was prescribed dual antiplatelet therapy with aspirin and clopidogrel until six months after the second procedure&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0025" class="elsevierStylePara elsevierViewall">At one-year follow-up the patient remains in NHYA class II&#44; with NT-proBNP level of 510 pg&#47;ml&#46; Transthoracic echocardiography revealed the two bioprostheses overlapping with appropriate transprosthetic gradients and associated mild to moderate leak &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0030" class="elsevierStylePara elsevierViewall">Malpositioning of the bioprosthesis during TAVI is a serious procedural complication which needs to be managed promptly to avoid vascular and other systemic complications&#46; Two prospective studies conducted in patients undergoing TAVI using the CoreValve<span class="elsevierStyleSup">&#174;</span> revealed a prevalence of valve dislocation after deployment of 3&#46;2-3&#46;9&#37;&#44; with no long-term vascular or neurological complications&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;3</span></a> Another study observed this complication in about 10&#37; of patients&#44; associated with lower survival rates and higher frequency of coronary ischemia&#44; stroke&#44; and renal failure&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Possible causes of malpositioning are mismatch of the annulus and valve size&#44; which can be solved by precise annulus measurements with echocardiographic and computed tomography imaging&#59; arrhythmias&#44; which hinder stabilization of the valve during deployment &#40;higher ventricular rate pacing is used to stabilize the valve&#41;&#59; and by accident&#44; after successful deployment during retraction of the delivery system&#44; if the anchors are not fully released from the deployment catheter or if the tip of the deployment catheter becomes caught at the proximal end of the prosthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0040" class="elsevierStylePara elsevierViewall">Besides morphological or patient-related factors&#44; operator experience appears to be crucial to the prevalence of valve dislocation&#46;<a class="elsevierStyleCrossRefs" href="#bib0030"><span class="elsevierStyleSup">1&#44;2</span></a> This was confirmed in a reference center&#44; in which the incidence of CoreValve<span class="elsevierStyleSup">&#174;</span> dislocation decreased constantly with increasing experience over a period of almost three years&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0045" class="elsevierStylePara elsevierViewall">Valve dislocation after complete deployment often results in the need to implant a second prosthesis&#44; which is a feasible and effective interventional option that appears to be safer than retrieving the first prosthesis&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> The decision whether to insert a new valve inside the previous one&#44; or to pull the first one to another location in the aorta and implant a second valve sequentially&#44; depends on various factors&#44; including operator preferences and procedural circumstances&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> When the two valves are positioned overlapping or partially overlapping each other&#44; there are various disadvantages&#58; duplication of the amount of metal residing against the native aortic wall increases the risk of covering the native coronary ostia and requires more time for endothelialization&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> Emergent surgery may be necessary in some cases&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0050" class="elsevierStylePara elsevierViewall">New transcatheter heart valves have been created in order to overcome some of the limitations of previous systems&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> The Portico<span class="elsevierStyleSup">&#174;</span> is a self-expanding transcatheter aortic bioprosthesis with novel capabilities&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Its ability to be repositioned&#44; recaptured&#44; and redeployed is a desirable feature&#44; especially when the initial implant positioning is suboptimal&#46; However&#44; only small series with limited follow-up have been published&#46;<a class="elsevierStyleCrossRef" href="#bib0045"><span class="elsevierStyleSup">4</span></a> Only one case of successful Portico<span class="elsevierStyleSup">&#174;</span> transcatheter aortic valve-in-valve implantation&#44; in a patient with a degenerated bioprosthesis &#40;placed surgically&#41;&#44; has been described to our knowledge&#46;<a class="elsevierStyleCrossRef" href="#bib0050"><span class="elsevierStyleSup">5</span></a> This is the first reported case of TAVI valve-in-valve with this type of bioprosthesis&#44; with good results at 12 months&#46; A valve-in-valve procedure with a self-expanding transcatheter bioprosthesis with repositioning features is presently the first-line solution in cases of degenerated biological prostheses or prosthesis displacement during TAVI&#46; However&#44; assessment of more patients in medium- and long-term follow-up is required&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Conclusions</span><p id="par0055" class="elsevierStylePara elsevierViewall">Dislocation of the bioprosthesis during TAVI is a serious procedural complication which needs to be managed promptly to avoid vascular and other systemic complications&#46; This report describes a successful valve-in-valve procedure after valve dislodgement&#44; with implantation of a self-expanding transcatheter bioprosthesis with repositioning capabilities&#46;</p></span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Ethical disclosures</span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Protection of human and animal subjects</span><p id="par0060" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Confidentiality of data</span><p id="par0065" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Right to privacy and informed consent</span><p id="par0070" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appear in this article&#46;</p></span></span><span id="sec0045" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0065">Conflicts of interest</span><p id="par0075" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transcatheter aortic valve implantation &#40;TAVI&#41; has become an important treatment in high surgical risk patients with severe aortic stenosis &#40;AS&#41;&#44; whose complications need to be managed promptly&#46;</p><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">The authors report the case of an 86-year-old woman presenting with severe symptomatic AS&#44; rejected for surgery due to advanced age and comorbidities&#46; The patient underwent a first TAVI&#44; with implantation of a Medtronic CoreValve<span class="elsevierStyleSup">&#174;</span>&#44; which became dislodged and migrated to the ascending aorta&#46; Due to the previous balloon valvuloplasty&#44; the patient&#39;s AS became moderate&#44; and her symptoms improved&#46; After several months&#44; she required another intervention&#44; performed with a St&#46; Jude Portico<span class="elsevierStyleSup">&#174;</span> repositionable self-expanding transcatheter aortic valve&#46; There was a good clinical response that was maintained at one-year follow-up&#46;</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">The use of a self-expanding transcatheter bioprosthesis with repositioning features is a solution in cases of valve dislocation to avoid suboptimal positioning of a second implant&#44; especially when the two valves have to be positioned overlapping or partially overlapping each other&#46;</p></span>"
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        "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">A implanta&#231;&#227;o de v&#225;lvula a&#243;rtica percut&#226;nea &#40;VAP&#41; tornou-se um procedimento importante no tratamento de doentes com estenose a&#243;rtica grave com elevado risco cir&#250;rgico&#44; cujas complica&#231;&#245;es devem ser avaliadas e tratadas de forma adequada&#46;</p><p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Os autores relatam o caso de uma doente de 86 anos&#44; com estenose a&#243;rtica grave sintom&#225;tica&#44; recusada para interven&#231;&#227;o cir&#250;rgica dada a idade avan&#231;ada e comorbilidades&#46; A doente foi submetida a uma primeira implanta&#231;&#227;o de VAP com uma v&#225;lvula <span class="elsevierStyleItalic">Medtronic CoreValve</span><span class="elsevierStyleSup">&#174;</span>&#44; a qual sofreu um deslocamento para a aorta ascendente durante o procedimento&#46; Devido &#224; angioplastia de bal&#227;o previamente efetuada&#44; a estenose a&#243;rtica tornou-se moderada&#44; com melhoria da sintomatologia da doente&#46; V&#225;rios meses depois&#44; por agravamento cl&#237;nico&#44; houve necessidade de reinterven&#231;&#227;o&#44; a qual foi realizada com um sistema reposicion&#225;vel <span class="elsevierStyleItalic">Portico</span><span class="elsevierStyleSup">&#174;</span>&#46; Verificou-se um segundo posicionamento valvular adequado&#44; com boa resposta cl&#237;nica da doente&#44; que persiste ap&#243;s um ano de <span class="elsevierStyleItalic">follow-up</span>&#46;</p><p id="spar0030" class="elsevierStyleSimplePara elsevierViewall">A utiliza&#231;&#227;o de sistemas reposicion&#225;veis de implanta&#231;&#227;o de VAP constitui&#44; atualmente&#44; uma solu&#231;&#227;o em casos de deslocamento da v&#225;lvula&#44; de forma a evitar uma segunda implanta&#231;&#227;o sub&#243;tima&#44; sobretudo quando as duas v&#225;lvulas t&#234;m de ficar em sobreposi&#231;&#227;o&#46;</p></span>"
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          "en" => "<p id="spar0035" class="elsevierStyleSimplePara elsevierViewall">Sequential procedures during the second intervention&#46; &#40;A and B&#41; Percutaneous coronary intervention of the mid left anterior descending artery with a drug-eluting stent&#59; &#40;C&#41; transfemoral transcatheter aortic valve implantation &#40;valve-in-valve&#41; under three-dimensional transesophageal echocardiographic guidance&#44; the Medtronic CoreValve<span class="elsevierStyleSup">&#174;</span> being immobilized with a 15 mm snare loop by a radial approach&#59; &#40;D&#41; aortic valve balloon valvuloplasty performed with a 20 mm NuMED Nucleus balloon&#44; followed by &#40;E and F&#41; implantation of a 25 mm St&#46; Jude Portico<span class="elsevierStyleSup">&#174;</span> valve&#59; &#40;G&#41; this valve was underexpanded and post-dilation was performed after changing the Amplatz super stiff wire for a backup Meier wire in order to advance the Nucleus balloon&#59; &#40;H&#41; final result&#46;</p>"
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      "titulo" => "References"
      "seccion" => array:1 [
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                      "autores" => array:1 [
                        0 => array:2 [
                          "etal" => true
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                            0 => "G&#46; Ussia"
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                  ]
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                      "doi" => "10.4244/EIJV7I11A203"
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                          "autores" => array:3 [
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