Successful Valve-in-Valve-in-Valve Transcatheter Aortic Valve Implantation for Severe Bioprosthetic Valve Restenosis in a High-Risk Patient

Figures

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  Figure 1. In the first frame the prosthetic valve delivery system is advanced into the previously placed bioprosthetic valves. The alignment and positioning are being carefully adjusted under fluoroscopic guidance to ensure optimal placement within the existing valve frames. In the second frame the valve is partially expanded, demonstrating precise alignment within the annular structure of the previously placed valves. The third frame shows the fully expanded third valve in position, with good apposition to the stent frames of the prior valves. The fluoroscopic image confirms the valve is securely deployed, with symmetrical stent expansion and no evident malposition.

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  Figure 2. The sagittal view demonstrates a ViViV TAVI within the native calcified aortic annulus. The orientation of the prosthetic valve is visualized with a well-expanded stent frame. Markers indicate the coronary ostia’s proximity to the prosthesis, particularly the LCA. ViViV: valve-in-valve-in-valve; TAVI: transcatheter aortic valve implantation; LCA: left coronary artery

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  Figure 3. The cross-sectional view shows the tri-leaflet structure of the valve with excellent circularity, confirming proper deployment and seating. The distances to the RCA and LCA are measured, showing adequate clearance. RCA: right coronary artery; LCA: left coronary artery

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  Figure 4. A detailed diagrammatic analysis illustrates the geometric assessment of the valve deployment. Measurements include minimum (25.2 mm) and maximum (25.9 mm) diameters, with a derived perimeter (80.3 mm) and area (512.5 mm²), confirming optimal prosthetic valve expansion. The proximity of the prosthesis to the LCA and RCA is also highlighted to evaluate coronary access post-procedure. RCA: right coronary artery; LCA: left coronary artery

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  Figure 5. The image illustrates key structural and procedural aspects of a ViViV TAVI procedure, focusing on the alignment and interaction of the stent frames and valve components. The top panel depicts the Evolut stent frame with nodes labeled 1 to 5, identifying the nadir of the leaflet at Node 3. The middle panel overlays an Evolut 23-mm valve with a second Sapien S3/S3 Ultra 20-mm valve, highlighting the NSP at Node 4, with measured dimensions of 18 mm from inflow to NSP and a Sapien valve height of 15.5 mm. A clearance of 2.5 mm between the S3 valve inflow and the lower stent node is also noted. The bottom panel provides detailed views of the commissure tab and stent frame top, emphasizing leaflet positioning within the stent geometry. ViViV: valve-in-valve-in-valve; TAVI: transcatheter aortic valve implantation; LCA: left coronary artery; NSP: neo-skirt position This image is created by the authors of this study.