Valve-in-Root TAVI vs Redo Surgery in a Young Adult With Failed Bioprosthesis.

TOPIC OF CONTROVERSY: Whether valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) or redo surgical aortic valve replacement (SAVR) is preferred for structural valve degeneration of a Freestyle stentless aortic root in a young adult, and whether a Ross procedure at index surgery would have better served lifetime management.

CASE SUMMARY: A 30-year-old man with a failed stentless aortic root (implanted at age 20 for bicuspid aortic valve regurgitation) presented with severe bioprosthetic regurgitation and ventricular dilatation. Transfemoral ViV TAVI with a 29-mm Edwards SAPIEN 3 Ultra Resilia was performed successfully.

PRO VIEWPOINT: ViV TAVI avoids redo sternotomy, preserves future options, and aligns with patient preference to avoid anticoagulation.

CON VIEWPOINT: Redo SAVR with a mechanical valve-and a Ross procedure at the index operation-may offer superior lifetime sequencing, avoiding constraints of successive transcatheter implants.

TAKE-HOME MESSAGE: Lifetime planning must begin at the index operation; both ViV TAVI and redo SAVR require heart team deliberation with explicit consideration of all future interventions.