Real-Time Hemodynamic Guidance During Valve-in-Valve TAVI

OBJECTIVES: To describe hemodynamic guidance during valve-in-valve transcatheter aortic valve implantation using simultaneous aortic and left ventricular pressure monitoring. KEY STEPS: A 90-year-old woman with a failed 19-mm surgical bioprosthesis and severe transvalvular regurgitation underwent valve-in-valve implantation with a self-expanding valve guided by a SavvyWire. During the first deployment, the aortic waveform remained completely flat after pacing was discontinued, whereas left ventricular pulsatility persisted; the valve was recaptured. During the second deployment, aortic pulsatility recovered after pacing cessation; final release was performed. Postdilatation reduced the invasive mean transvalvular gradient from 23 to 11 mm Hg. POTENTIAL PITFALLS: A flat aortic waveform with preserved left ventricular pulsatility is a warning sign warranting system confirmation and multimodality reassessment, not a specific diagnosis of leaflet dysfunction. TAKE-HOME MESSAGE: Simultaneous pressure monitoring can complement fluoroscopy when valve function is uncertain during deployment and may support timely recapture when abnormal hemodynamics persist.