Transcatheter Aortic Valve-in-Surgical Aortic Valve (TAV-in-SAV) for Structural Valve Degeneration of Post-Surgical Aortic Valve Replacement (SAVR) With the 3D-Nicks Procedure: A Case Report.

Transcatheter aortic valve implantation (TAVI) for structural valve deterioration (SVD) following surgical aortic valve replacement (SAVR) is an established alternative to redo surgery (transcatheter aortic valve-in-surgical aortic valve, or TAV-in-SAV). However, in patients with a small aortic annulus or small sinus of Valsalva (SOV), the risk of coronary artery obstruction or severe prosthesis-patient mismatch (PPM) remains a major constraint. To address this, we previously introduced the "3D-Nicks" procedure, using a preoperatively prepared three-dimensional ellipsoidal patch to achieve circumferential aortic root enlargement. We report a 14-year successful clinical course of TAV-in-SAV following SAVR with the 3D-Nicks procedure. A 61-year-old woman with severe aortic valve stenosis (AS) and a narrow aortic root (annulus 19 mm, STJ 20 mm) underwent SAVR (CEP19®︎ mm, Edwards Lifesciences, Irvine, CA) combined with the 3D-Nicks technique. Around 14 years postoperatively, she developed severe SVD. Contrast CT demonstrated that 3D-Nicks had maintained ample root geometry (SOV 30.2-36.8 mm, STJ 31.8 mm, VTC > 5.0 mm, VTSTJ > 6.0 mm). TAV-in-SAV was successfully performed using a 23 mm Evolut FX®︎ valve (Medtronic, Minneapolis, MN) via transfemoral access without coronary protection. Postoperative echocardiography showed excellent hemodynamics (mean PG 6 mmHg, EOAi 1.29 cm²/m²), which remained stable at the three-year follow-up (EOAi 1.16 cm²/m²). This case highlights that the 3D-Nicks procedure may provide favorable three-dimensional aortic root dimensions that facilitate safe long-term TAV-in-SAV.