Transcatheter Aortic Valve-in-Valve-in-Valve Replacement in a Young Woman With Transcatheter Structural Valve Deterioration Within a Degenerated Aortic Root Homograft.

Transcatheter aortic valve replacement is a well-established procedure for older patients with symptomatic, severe aortic stenosis. However, data are lacking on its durability and long-term complications, particularly in young patients and patients treated for aortic valve regurgitation. This article describes the case of a 27-year-old woman with complex congenital cardiovascular disease who, after 4 previous aortic valve replacement procedures, presented with structural deterioration of her most recent replacement valve, which had been placed by transcatheter aortic valve replacement inside a failed aortic root homograft 6 years earlier. After the patient had undergone this transcatheter aortic valve replacement procedure to treat aortic valve regurgitation related to her degenerated aortic root homograft, she became pregnant and successfully carried her high-risk pregnancy to term. However, the replacement valve deteriorated during the late stages of pregnancy, resulting in substantial hemodynamic changes between the first trimester and the postpartum period. To avoid repeat sternotomy, a redo transcatheter valve-in-valve replacement procedure procedure was performed through the right carotid artery. Because the patient wanted to have more children and therefore avoid anticoagulation, a SAPIEN 3 transcatheter valve (Edwards Lifesciences) was placed as a bridge to a future, more-durable aortic root replacement. The result in this case suggests that in patients with complex adult congenital pathology, transcatheter aortic valve replacement can be used as a temporizing bridge to subsequent, definitive aortic valve repair.