First Report of Antegrade Transeptal Valve-in-Valve TAVR

Q: What is the clinical evidence from this study?

Study design: Case Report. Population: Acute aortic stenosis / Failing bioprosthetic aortic valve (n=1). Intervention: Antegrade transseptal valve-in-valve TAVR. Primary outcome: Mean transvalvular pressure gradient.

Jeffrey Rossi; Robert Hoffberger; Thomas P. Archer; David Buck; Michael Mollod; Daniel Molloy; Jonathan Hoffberger; Jeffrey Sell

doi:10.1016/j.jaccas.2026.110191

September 1, 2026JACC Case ReportsOpen Access

First Report of Antegrade Transeptal Valve-in-Valve TAVR

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Key result

Transseptal antegrade ViV TAVR offers a viable option when standard access routes are unavailable.

n=1

Figures

Graphical abstract published by JACC Case Reports — Graphical abstract · Published by JACC Case Reports · CC BY-NC-ND

Why the study?

A transfemoral, antegrade valve-in-valve TAVR procedure is needed for patients with no other access options, but procedural steps and feasibility were not previously outlined.

Does antegrade transseptal valve-in-valve TAVR provide a safe and feasible procedural option in a high-risk patient with severe aortic stenosis and no alternative access routes?

Key Points

To describe the procedural technique for antegrade transseptal valve-in-valve transcatheter aortic valve replacement in a patient with no standard surgical or catheter access options.
Treated a 66-year-old man with severe aortic stenosis, heart failure, and extensive aortic dissection that precluded standard transfemoral, alternative arterial, transcaval, or transapical access.
Performed a transseptal puncture from the femoral vein, crossed the mitral and aortic valves into the ascending aorta, and snared the wire via femoral arterial access to create a veno-arterial rail.
Delivered a 26-F protective sheath through the mitral valve to deploy a 23-mm balloon-expandable valve inside the failing surgical bioprosthesis.
Echocardiography verified preserved mitral valve apparatus integrity without structural damage or chordal disruption.
The patient recovered without procedural complications and was discharged from the hospital.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

Does antegrade transseptal valve-in-valve TAVR provide a safe and feasible procedural option in a high-risk patient with severe aortic stenosis and no alternative access routes?

P

Population

A 66-year-old man with a failing bioprosthetic aortic valve, severe comorbidities, and extensive vascular disease preventing traditional access who underwent an antegrade transseptal valve-in-valve TAVR.

I

Intervention

Antegrade transseptal valve-in-valve transcatheter aortic valve replacement (TAVR) using a 23 S3 Ultra Resilia Valve deployed via a veno-arterial rail and 26-F protective sheath through the mitral valve.

O

Outcome

Procedural feasibility, valve deployment gradient, and survival to hospital discharge.safety

Limitations

Added procedural complexity requiring transseptal puncture and an external veno-arterial rail
Potential for damage to the mitral valve chordal structures
Risk of leaflet entanglement or vascular complications
Only a single case report with limited evidence regarding long-term safety and efficacy
Added procedural complexity (transseptal puncture, external rail)
Risk of damage to the mitral valve apparatus
Risk of atrial perforation and pericardial effusion
Limited evidence based on single cases/small series

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Implication

Antegrade transseptal valve-in-valve TAVR may serve as a viable life-saving alternative for high-risk patients lacking any traditional or alternative vascular access options.

Abstract

OBJECTIVE: To outline the procedural steps for a transfemoral, antegrade valve in a transcatheter aortic valve replacement procedure in a patient with no other access options. KEY STEPS: Gain femoral venous and arterial access. Position a snare in the ascending aorta. Perform transseptal puncture. From the left atrium, deliver an 0.035-inch wire through the mitral valve and aortic valve into the ascending aorta. Snare the wire in the aorta and create a venous-arterial rail. Deliver a large-bore sheath through the mitral valve. Deliver the transcatheter valve through the sheath over the rail antegrade into the aortic valve. POTENTIAL PITFALLS: Possible complications include inability to deliver the valve across the acute turn from the mitral valve through the aortic valve and damage to the mitral valve chordal structures. TAKE-HOME MESSAGE: Transseptal antegrade transcatheter aortic valve replacement represents a viable treatment option for valve-in-valve patients who are high risk for open surgery and with no other alternative access options.

Discussion

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Cite This Study

Rossi et al. (2026) conducted a case report in Acute aortic stenosis / Failing bioprosthetic aortic valve (n=1). Antegrade transseptal valve-in-valve TAVR was evaluated on Mean transvalvular pressure gradient. Antegrade transseptal valve-in-valve TAVR was successfully performed in a patient with no traditional access options, reducing the mean transvalvular gradient from 18 mm Hg to 7 mm Hg.

synapsesocial.com/papers/6ac19d70aeea5716e8c6c674 https://doi.org/10.1016/j.jaccas.2026.110191

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First Report of Antegrade Transeptal Valve-in-Valve TAVR

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

First Report of Antegrade Transeptal Valve-in-Valve TAVR

Figures

Key Points

Study Design

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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