# TAV-in-TAV to Rescue Suboptimal Index TAVR: The Critical Role of Anatomy

## TL;DR

This case study shows how a second TAVR procedure can fix a failed first one by carefully considering the patient's anatomy and device positioning.

## Contribution

Highlights the importance of anatomical evaluation and precise device positioning in TAV-in-TAV procedures.

## Key findings

- A high-positioned Sapien 3 Ultra valve-in-valve resolved moderate paravalvular leak after a failed ACURATE neo2 TAVR.
- Meticulous coronary protection and balloon postdilatation achieved successful outcomes without coronary compromise.
- Anatomical constraints guided the successful TAV-in-TAV intervention in a complex case.

## Abstract

Suboptimal transcatheter aortic valve replacement (TAVR) positioning can lead to inadequate sealing between the prosthesis and the native annulus, resulting in significant paravalvular leak (PVL).

A 75-year-old woman underwent TAVR with an ACURATE neo2 valve that was complicated by severe intraprocedural aortic regurgitation and hemodynamic instability, resulting in prompt deployment of the valve, with residual moderate PVL. Initial symptomatic relief was short-lived owing to progressive heart failure. Anatomical evaluation revealed substantial constraints, guiding the successful implantation of a high-positioned Sapien 3 Ultra transcatheter valve-in-valve (TAV-in-TAV). Meticulous coronary protection and iterative balloon postdilatation resolved PVL without coronary compromise.

This case emphasizes the critical role of detailed anatomical evaluation and precise device positioning in TAV-in-TAV procedures, particularly when managing risks associated with specific valve prosthesis features, such as ACURATE neo2 upper crowns.

Detailed anatomical assessment and meticulous device positioning are fundamental for successful outcomes in complex TAV-in-TAV interventions.