Valve-in-Valve Transapical Transcatheter Aortic Valve Replacement with Concomitant Percutaneous Coronary Intervention: A Case Report.

BACKGROUND Valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) is increasingly used, as older high-risk patient populations require repeat aortic valve replacements. The most common approach to ViV-TAVR is through a transfemoral approach or alternative vascular access sites, such as transcarotid or transsubclavian TAVR. Within this population, some patients become ineligible for ViV-TAVR due to contraindications, such as severe peripheral vascular disease, necessitating an alternative. Transapical TAVR allows for TAVR even in the context of severe peripheral vascular disease, although it has rarely been used in the ViV-TAVR setting, and even less frequently with concomitant percutaneous coronary intervention. CASE REPORT We present the case of a 79-year-old man with a history of coronary artery disease and aortic valve disease 9 years after coronary artery bypass grafting and aortic valve replacement presenting with progressive dyspnea on exertion. The patient was found to have severe prosthetic valve degeneration but had a high preoperative surgical risk score and severe peripheral arterial disease. Transfemoral, carotid, and subclavian access were contraindicated given the severe vascular disease, and therefore the patient underwent transapical ViV-TAVR with a 26-mm Sapien S3 valve and a left main coronary artery snorkel stent for protection of the left main coronary. CONCLUSIONS With this rare documented case of transapical ViV-TAVR, we highlight the importance of having several available alternative surgical approaches to TAVR for patients who are ineligible for transfemoral ViV-TAVR and have high preoperative risk scores.