# Anesthetic Management for Valve-in-Valve Transcatheter Aortic Valve Replacement (TAVR) After Primary TAVR Failure With Mixed Aortic Valve Dysfunction

## TL;DR

This paper describes a successful redo TAVR procedure in a high-risk patient using detailed imaging, real-time guidance, and proactive strategies to ensure safety and recovery.

## Contribution

The paper presents a novel anesthetic and procedural approach for high-risk redo TAVR with mixed aortic valve dysfunction.

## Key findings

- Detailed preoperative imaging and real-time TEE guidance ensured successful valve deployment and hemodynamic stability.
- Proactive vasoactive strategies countered pacing-induced hypotension and enabled fast-track recovery.
- Post-deployment imaging confirmed no complications and immediate improvement in valve function.

## Abstract

Redo valve-in-valve transcatheter aortic valve replacement (TAVR) confronts anesthesiologists with compounded hemodynamic and neurologic risk. We managed an 85-year-old male with severe mixed prosthetic aortic dysfunction whose pre-procedural transthoracic echocardiogram showed a peak velocity of 3.7 m/s⁻¹, a mean gradient of 24 mm Hg, an effective orifice area of 0.8 cm², and a posteriorly directed, eccentric regurgitant jet filling >50% of the left ventricular outflow tract. The failure was suspected to have been caused by structural valve deterioration within five years after the initial TAVR. CT confirmed adequate coronary heights and true-lumen dimensions for a 26 mm Sapien 3 Ultra Resilia valve.

General anesthesia was induced with 20 mg of etomidate and 200 mcg of fentanyl and maintained with low-dose propofol (50-100 mcg/kg/min) and remifentanil (0.05-0.1 mcg/kg/min), permitting rapid titration around two rapid-ventricular-pacing (180 bpm) runs. Continuous transesophageal echocardiography (TEE)-guided balloon valvuloplasty, valve deployment, and real-time assessment of ventricular filling; anticipatory epinephrine infusion plus norepinephrine boluses countered pacing-induced hypotension. Cerebral oximetry monitored regional saturation during hemodynamic excursions.

Intra-procedural TEE confirmed coaxial positioning, full expansion of the new prosthesis, and immediate abolition of the eccentric regurgitant jet. Post-deployment deep-gastric views demonstrated a peak velocity of 2.3 ms⁻¹, trivial central regurgitation, and preserved biventricular function; aortic-root angiography corroborated the absence of coronary obstruction or paravalvular leak. The patient was extubated in the hybrid suite, required <2 h of low-dose norepinephrine (0.02-0.06 mcg/kg/min), ambulated on postoperative day one, and was discharged home on day two.

This case illustrates how detailed preoperative imaging, real-time TEE guidance, and proactive vasoactive strategies enable hemodynamic stability, neuroprotection, and fast-track recovery in high-risk redo TAVR.