Index Transcatheter Aortic Valve Expansion After TAV-in-TAV Using a One-Size-Smaller SAPIEN Valve

Index transcatheter aortic valve (TAV) expansion during TAV-in-TAV is crucial as it changes the valve-to-aorta distances and may increase the intraprocedural risk. A TAV-in-TAV procedure was planned for a 90-year-old woman with prior TAV replacement (23-mm SAPIEN XT) who presented with prosthetic valve stenosis. Second TAV sizing was assessed by averaging the stent areas of the index TAV and by drawing a virtual circle on preprocedural computed tomography (CT). CT imaging also revealed significant calcification of the index TAV leaflets. The team opted for a one-size-smaller 20-mm SAPIEN3 valve. During the procedure, the index TAV expanded by creating a gap between the 2 valve stents. Postprocedural CT confirmed index TAV expansion and the calcified leaflets in the gap, which likely facilitated the expansion. Our case highlights the importance of considering leaflet calcification of the index TAV when planning TAV-in-TAV, which includes second TAV sizing and predicting index TAV expansion.