TAV-in-TAV-in-SAV in a Patient With Prior Mitral Valve-in-Valve.

OBJECTIVE

Successful deployment of a third self-expanding transcatheter aortic valve within a failed balloon-expandable valve in a surgical aortic valve bioprosthesis.

KEY STEPS: Access and hemodynamics setup: 2 arterial and 1 venous access. Valve crossing and valvuloplasty: Cross the degenerated prosthetic valve complex without disrupting the mitral prosthesis to preserve its integrity, followed by valvuloplasty. Valve delivery and deployment: Transcatheter heart valve positioning utilizing fluoroscopic markers. Postdeployment assessment: Invasive hemodynamic assessment for assessment of transaortic gradient.

POTENTIAL PITFALLS: Transcatheter aortic valve in transcatheter aortic valve in surgical aortic valve with prior mitral valve-in-valve without disrupting the mitral valve-in-valve integrity whilst still deploying the aortic valve-in-valve-valve successfully, based on the anatomical configuration of the 2 valves.

TAKE-HOME MESSAGE: Transcatheter aortic valve in transcatheter aortic valve in surgical aortic valve may be considered in selected high-risk patients, but coronary sequestration, cumulative frame geometry, and underexpansion require assessment.