# Optimizing Valve Selection in Valve-in-Valve Transcatheter Aortic Valve Replacement: A Case Study on Addressing Patient-Prosthesis Mismatch and Early Structural Valve Deterioration in a Morbidly Obese Patient

## TL;DR

This case study explores how careful valve selection in TAVR can prevent complications in obese patients with aortic valve stenosis.

## Contribution

The study presents a novel approach to addressing patient-prosthesis mismatch and early valve deterioration in a morbidly obese patient through valve-in-valve TAVR.

## Key findings

- A 29 mm Medtronic Evolut Fx valve improved indexed effective orifice area after early structural valve deterioration from a 26 mm Edwards Sapiens 3 valve.
- Patient-prosthesis mismatch in obese patients can lead to early structural valve deterioration.
- Valve-in-valve TAVR is an effective strategy for managing TAVR complications in complex cases.

## Abstract

Transcatheter aortic valve replacement (TAVR) has increasingly become a fundamental approach for treating aortic valve stenosis (AVS), especially in high surgical risk patients. This case study underscores the criticality of meticulous procedural planning and precise valve selection in patients with severe AVS compounded by obesity. We report a case of a patient who, after receiving a 26 mm Edwards Sapiens 3 valve, presented with worsening exertional dyspnea and a declining indexed effective orifice area (EOAi). This deterioration indicated early structural valve deterioration (SVD), presumably due to patient-prosthesis mismatch (PPM). A subsequent valve-in-valve (ViV) TAVR using a 29 mm Medtronic Evolut Fx valve was successfully executed, leading to a notable improvement in EOAi. This case study emphasizes the complexities inherent in valve choice and sizing in TAVR, particularly highlighting the impact of PPM on obese patients and its potential to precipitate early SVD. The report further explores the emerging strategies in addressing TAVR valve dysfunctions via ViV interventions, shedding light on the nuanced and dynamic nature of TAVR management in obese patients. It advocates for tailored treatment strategies in managing such intricate cases, demonstrating the evolving landscape of TAVR procedures.