First Report of Antegrade Transeptal Valve-in-Valve TAVR: Revisiting an Old Strategy

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.

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.

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.

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.