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Repeat ViV-TAVI Considerations — EECC MCQ

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HardValvular Heart DiseaseRepeat ViV-TAVI ConsiderationsEECC

A 78-year-old man with bioprosthetic aortic valve degeneration (SVD) presents with progressive HF. His STS-PROM score is 12% (high surgical risk). 4D-CT shows a satisfactory internal diameter of the degenerated prosthesis. He has already had one valve-in-valve TAVI. Can another ViV-TAVI be performed?

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Correct answer: C — A second valve-in-valve (ViV) TAVI ('Russian doll') may be technically possible but significantly increases the risk of coronary obstruction and patient-prosthesis mismatch due to progressive reduction in internal diameter; careful CT planning and Heart Team discussion are essential

Sequential ViV-TAVI ('TAVI-in-TAVI-in-surgical-valve') is emerging as clinical scenarios arise, but carries specific risks: (1) progressive reduction in internal diameter with each device — increasing the risk of patient-prosthesis mismatch (elevated residual gradients); (2) increased coronary obstruction risk (leaflets progressively closer to coronary ostia with each additional frame); (3) conduction disturbance risk (additive compression of the conduction system). The 2025 ESC VHD Guidelines acknowledge this as an evolving area and emphasise that lifetime valve management (considering how many future procedures a patient may need) should factor into the initial valve choice. CT planning for coronary height, sinus of Valsalva dimensions, and virtual THV sizing is essential.

Reference: ESC/EACTS (2025): VHD Guidelines