High-Risk TAV-in-TAV: Balloon-Expandable TAVR in a Degenerated Mechanically Expanded Valve

The objective of this study is to describe a high-risk transcatheter aortic valve-in-valve in a Lotus valve requiring coronary artery protection.

Thorough preoperative assessment for valve sizing and coronary obstruction risk assessment are performed. Access is obtained for a pigtail catheter, a guiding catheter for percutaneous coronary intervention, and the transcatheter aortic valve replacement delivery system. Coronary access is secured with a coronary wire and a guide extension catheter before valve deployment. Proper alignment of the new valve is ensured. A snorkel stent is deployed and maximal expansion is ensured.

Coronary artery anatomy, which is at high risk for obstruction, can lead to coronary ischemia or sequestration after valve deployment. Improper alignment of the new valve can lead to poor apposition and paravalvular leak. Injury to the aorta during valve deployment or when postdilation is required.

Successful transcatheter aortic valve-in-valve in a Lotus valve is feasible with proper preoperative planning, individualized device selection, and coronary protection when indicated.