Transcatheter aortic valve replacement-in-transcatheter aortic valve replacement for high-risk anatomies: Demonstrating the feasibility of index leaflet overhang in a first-in-human case report

Background: Transcatheter aortic valve replacement (TAVR)-in-TAVR within index supra-annular transcatheter heart valves (THVs) and high-risk anatomy can compromise coronary perfusion and re-access. Case summary: An 80-year-old male presented with acute heart failure caused by degeneration of an Evolut R THV, leading to severe aortic regurgitation. Aortic computed tomography imaging revealed a high-risk anatomy characterized by the index THV's commissural plane being placed above the coronary ostia and a valve-to-aorta distance of less than 2 mm, resulting not eligible for redo-TAVR according to recent literature. The current case represents the first-in-human application of redo-TAVR with low SAPIEN 3 THV implantation within an Evolut R THV obtaining index leaflet overhang, preserving coronary perfusion and potential coronary re-engagement. Discussion: Following in vitro study, this case demonstrates in vivo feasibility of redo-TAVR with low SAPIEN 3 THV implantation within an Evolut R THV obtaining index leaflet overhang.