CT and Fluoroscopic Analyses of Valve Expansion in Redo-TAVR: A First-in-Human Report

Redo transcatheter aortic valve replacement (TAVR) for transcatheter aortic valve (TAV) failure is becoming increasingly common. Although short-term outcomes appear favorable, no imaging after redo-TAVR has been performed to evaluate frame expansion and geometry.

The authors report a first-in-human experience using multidetector computed tomography (MDCT) and fluoroscopy to evaluate valve frame expansion and geometry of both index and second TAVs.

From January 2023 to April 2025, 30 of 40 consecutive patients underwent redo-TAVR for bioprosthetic valve failure and had evaluable postprocedural MDCT. Index TAVs were predilated in 80% (24 of 30), and both TAVs were postdilated in all cases for frame optimization. Frame dimensions were measured using MDCT and fluoroscopy for both index and second TAVs at different levels. Valve expansion and eccentricity were calculated by comparing observed measurements with expected nominal measurements validated from previous studies.

TAV-in-TAV combinations were as follows: 8 of 30 (26.7%) short-in-short, 16 of 30 (53.3%) short-in-tall (15 Evolut, 1 Navitor), and 6 of 30 (20%) tall-in-short. Structural valve deterioration was the common mechanism of failure. Both MDCT and fluoroscopy showed that index TAVs were all underexpanded, and expansion was seen after redo-TAVR in all cases. The second TAVs were underexpanded across all valve types, but more so with tall-in-short (Evolut-in-SAPIEN) combination. No elevated valve gradients and no hypoattenuated leaflet thickening were observed at 30 days.

There was significant underexpansion of both index and second TAVs after redo-TAVR, irrespective of valve type and combinations. Larger studies are needed to validate this finding and determine the longer term impact of underexpansion of the second TAV, despite acceptable short-term hemodynamic performance.