TAV-in-TAV to rescue suboptimal index TAVR: the critical role of anatomy

<p dir="ltr">Background: 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). </p><p dir="ltr">Case Summary: 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. </p><p dir="ltr">Discussion: 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. </p><p dir="ltr">Take-Home Message: Detailed anatomical assessment and meticulous device positioning are fundamental for successful outcomes in complex TAV-in-TAV interventions.</p>