Transcatheter aortic valve-in-valve implantation for the treatment of a failed surgical bioprosthesis of small size

In the last decades, the wide use of surgical aortic bioprostheses translated into an increased rate of valve degeneration and dysfunction. However, most patients are excluded from surgical re-do due to high or prohibitive operative risk. In this clinical context, valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) has been shown to be effective. Nevertheless, some relevant concerns, such as elevated residual transvalvular gradient and coronary artery obstruction, still remain. Detailed information regarding the degenerated surgical bioprosthesis and a thorough analysis of the computed tomography scan are essential for accurate pre-procedural planning and may avoid dramatic acute complications. Moreover, in difficult cases, the use of some tips and tricks may help expert operators to achieve better results.Here we report the case of a patient affected by structural degeneration of a small label size surgical aortic valve, who was excluded from surgical reintervention due to high operative risk. Therefore, we decided to perform a ViV-TAVI despite the presence of challenging features.