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

Figures

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  Figure 1. Nested Aortic Prostheses and Relationship to the Mitral Valve-in-Valve Preprocedural computed tomography (CT) volume rendering demonstrates the surgical aortic frame containing the prior balloon-expandable transcatheter aortic valve (TAV) (A). The stretched reconstruction shows the proximity and protrusion of the mitral valve-in-valve prosthesis relative to the aortic valve complex (B), informing selection of a fluoroscopic trajectory that avoided interaction with the mitral prosthesis.

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  Figure 2. Underexpansion of the Prior SAPIEN 3 Cross-sectional computed tomography measurements show underexpansion and eccentricity of the 23-mm SAPIEN 3 within the 21-mm Magna 3,000 surgical valve. The inflow measured 19.5 × 22.1 mm with area 349.5 mm2 and perimeter-derived diameter 21.2 mm (A); the outflow measured 21.7 × 22.9 mm with area 396.0 mm2 and perimeter-derived diameter 22.5 mm (B).

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  Figure 3. Aortic Root and Coronary Measurements Preprocedural computed tomography shows sinus of Valsalva diameters of 32.4 mm, 31.9 mm, and 32.8 mm (A) and a sinotubular junction of 25.6 × 26.1 mm (B). Left coronary (LC) and right coronary (RC) heights were 15.2 mm (C) and 19.6 mm (D), respectively. These measurements were integrated with valve-to-coronary and neoskirt analyses when evaluating redo-transcatheter aortic valve replacement feasibility. STJ = sinotubular junction.

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  Figure 4. Predicted Coronary Obstruction and Sinus Sequestration Risk Virtual valve analysis demonstrated valve-to-coronary distances of 5.9 mm for the left coronary artery (LCA) (A) and 7.4 mm for the right coronary artery (RCA) (B). The predicted neoskirt height was 18.2 mm at the left coronary cusp (LCC) and 17.7 mm at the right coronary cusp, whereas the neoskirt plane remained more than 2 mm below the sinotubular junction (STJ) (C), supporting low predicted obstruction and sinus sequestration risk.

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  Figure 5. Mitral Prosthesis Relationship and Procedural Projection The stretched computed tomography view demonstrates the relationship between the aortic and mitral prosthetic complexes (A). Volume-rendered reconstructions reproduce the steep RAO 35°/caudal 35° projection used to cross and treat the aortic valve complex while driving past the mitral prosthesis (B), with an additional LAO 5°/caudal 28° view for frame orientation (C). LAO = left anterior oblique; RAO = right anterior oblique.

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  Figure 6. Hemodynamic and Echocardiographic Result The hemodynamic summary demonstrates severe preprocedural prosthetic obstruction with a mean gradient of 49 mm Hg. Following Evolut FX+ implantation, the invasive mean gradient decreased to 4 mm Hg with a well-seated valve and no significant aortic regurgitation on imaging. The dynamic fluoroscopic, pressure, and echocardiographic correlation is shown in (Video 7). AO = aortic pressure; ARI = aortic regurgitation index; LV = left ventricle.

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  Visual Summary. Stepwise Lifetime Aortic Valve Management The timeline summarizes serial valve therapy from surgical aortic and mitral valve replacement in 2006 through transcatheter aortic valve in surgical aortic valve (TAV-in-SAV) in 2019, mitral valve-in-valve replacement in 2022, and Evolut FX+ transcatheter aortic valve in transcatheter aortic valve in surgical aortic valve (TAV-in-TAV-in-SAV) in 2026. CT-guided assessment, staged balloon preparation, and frame-guided deployment reduced the mean aortic gradient from 49 to 4 mm Hg. CT = computed tomography.