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The treatment of coronary artery disease (CAD) in patients with severe aortic valve stenosis (AVS) eligible for transcatheter aortic valve implantation (TAVI) is not supported by clinical evidence, and the role of physiology over anatomy as well as the timing of coronary intervention are not defined. FAITAVI (ClinicalTrials.gov: NCT03360591) is a nationwide prospective, open-label, multicentre, randomised controlled study comparing the angiography-guided versus the physiology-guided coronary revascularisation strategy in patients with combined significant CAD and severe AVS undergoing TAVI. Significant CAD will be defined as coronary stenosis ≥50%, as assessed by visual estimation in vessels ≥2.5 mm. Physiology will be tested by fractional flow reserve (FFR) and instantaneous wave-free ratio (iFR). The study will be conducted at 15 sites in Italy. In the angiography arm, percutaneous coronary intervention (PCI) will be performed either before TAVI, during the TAVI procedure - before or after the valve implantation - or within 1 month±5 days of the valve implantation, left to the operator's decision. In the physiology arm, FFR and iFR will be performed before TAVI, and PCI will be indicated for FFR ≤0.80, otherwise the intervention will be deferred. In case of borderline values (0.81-0.85), FFR and iFR will be repeated after TAVI, with PCI performed when needed. With a sample size of 320 patients, the study is powered to evaluate the primary endpoint (a composite of death, myocardial infarction, stroke, major bleeding, or ischaemia-driven target vessel revascularisation). TAVI indication, strategy and medical treatment will be the same in both groups. After discharge, patients will be contacted at 1, 6, 12 and 24 months after the procedure to assess their general clinical status, and at 12 months for the occurrence of events included in the primary and secondary endpoints. FAITAVI is the first randomised clinical trial to investigate "optimal" percutaneous coronary intervention associated with TAVI in patients with severe AVS and CAD.

Trancatheter heart valve (THV) thrombosis is effectively treated with anticoagulation but alternative therapies are required when a faster gradient reduction is needed. Open heart surgery has been rarely performed due to the high perioperative mortality and only five cases have been described so far. Here we describe a case of emergent surgical explantation for THV thrombosis after a valve-in-valve. A 67years old man underwent transcatheter aortic valve implantation for a failed surgical bioprosthesis Epic 21mm (St. Jude Medical; St. Paul, Minnesota, US). A CoreValve 23mm (Medtronic, Minneapolis, Minnesota, US) was implanted through femoral access under conscious sedation without complications. Mean transvalvular gradient was effectively reduced (33mmHg vs 16mmHg) with no more than mild residual aortic regurgitation. After 8days the patient was discharged on dual antiplatelet therapy but was readmitted to the intensive care unit for pulmonary oedema 13days later. Echocardiography showed a raised transvalvular mean gradient (mean gradient change from discharge=15mmHg) without aortic regurgitation. Heart Team decided for emergent open heart surgery for the hemodynamic instability. On direct inspection THV was well positioned inside the surgical bioprosthesis but two cusps were covered by thrombus which markedly restricted their mobility. The THV and the former surgical valve were explanted and a new larger stented bioprosthesis was implanted. Thrombosis of the THV was confirmed on microscopic examination which showed no signs of inflammation or degeneration. The patient was discharged after 1month and the 3month follow up showed stable transvalvular gradients., (Copyright © 2017 Elsevier Inc. All rights reserved.)

Background and Aim of the Study: Although transcatheter aortic valve implantation (TAVI) is a steadily expanding treatment for the pathology of the aortic valve, its role in the replacement of native aortic valves following valve-sparing surgery has not been investigated., Methods: Among 150 patients who underwent TAVI at the authors' institution, three (2%) had a failed valve-sparing operation. The in-hospital outcome, mid-term mortality, and valvular function of the three patients were evaluated retrospectively. These patients, who were deemed at high surgical risk by the heart team, underwent TAVI for predominant severe aortic stenosis (n = 2) or pure severe aortic regurgitation (AR) (n = 1)., Results: A self-expandable CoreValve prosthesis was inserted via femoral access in all three patients. Based on the Valve Academic Research Consortium 2 criteria (VARC-2), implantation was successful in all cases, with only one major access site complication and no more than mild residual AR. At a follow up of 13 ± 6 months there were no deaths and the mean transvalvular gradient remained low (7 ± 6 mmHg at discharge; 7 ± 4 mmHg at follow up), without any echocardiographic signs of valve deterioration., Conclusions: The results obtained with this small patient cohort demonstrated the feasibility, safety, and favorable mid-term outcomes of TAVI for failed valve-sparing operations in high surgical risk patients. However, these findings must be validated in larger cohorts before extending such treatment routinely to this subset of patients.