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April 3, 2026CureusOpen Access

Successful Valve-in-Valve-in-Valve Procedure in a Patient With Severe Aortic Prosthesis Dysfunction: A Case Report

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Why the study?

As TAVI expands, repeated transcatheter valve implantations are increasingly needed but carry heightened risks of complications such as patient-prosthesis mismatch, impaired coronary access, and aortic regurgitation.

Does implantation of a self-expanding supra-annular valve in a valve-in-valve-in-valve configuration improve severe transvalvular regurgitation in a patient with failed balloon-expandable transcatheter valves?

Comparison

Self-expanding supra-annular valve implantation in a valve-in-valve-in-valve configuration

Design

Case report

Key result

Implantation of a self-expanding supra-annular prosthesis in a valve-in-valve-in-valve configuration successfully restored valve competence and improved functional status to NYHA class I at 18 months.

Authors

RERamiz EminiDADalal S AlshammariFAFayez Ammar S Alshammari

Discussion

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Overview

May warrant consideration in complex redo TAVI with failed balloon-expandable valves; extends options but remains hypothesis-generating.

Key Points

  • The case aims to explore the potential for complex valve procedures in managing severe aortic prosthesis dysfunction.
  • Case report of a patient with severe aortic regurgitation and heart failure.
  • Procedure involved implantation of a third prosthesis in a valve-in-valve-in-valve configuration.
  • Transition from balloon-expandable to self-expanding valve technology.
  • Successful correction of transvalvular regurgitation.
  • Preserved adequate effective orifice area post-implantation.
  • Demonstrated improved outcomes in a complex case of redo TAVI.

Study Design

Type

Case Report (n=1)

Multicenter

No

Structured PICO

Does implantation of a self-expanding supra-annular valve in a valve-in-valve-in-valve configuration improve severe transvalvular regurgitation in a patient with failed balloon-expandable transcatheter valves?

P
Population
1 74-year-old woman with severe symptomatic aortic stenosis and high surgical risk (STS score 12.43%, logistic EuroSCORE II 8.99%) who experienced early failure of two balloon-expandable transcatheter valves resulting in severe transvalvular regurgitation and recurrent heart failure (NYHA class IV).
I
Intervention
Implantation of a third prosthesis using a self-expanding supra-annular transcatheter heart valve in a valve-in-valve-in-valve (ViViV) configuration via the right femoral artery.
O
Outcome
Restoration of valve competence and clinical recovery (resolution of severe regurgitation and heart failure symptoms).

Switching from a balloon-expandable to a self-expanding supra-annular valve in a valve-in-valve-in-valve configuration is a feasible and effective strategy to correct severe transvalvular regurgitation in complex redo TAVI procedures.

Limitations

  • Describes the clinical course of a single patient, which limits the generalizability of the findings
  • Follow-up duration of 18 months remains relatively short for assessing the long-term durability of a valve-in-valve-in-valve configuration

Cite This Study

Emini et al. (2026) conducted a case report in Severe aortic prosthesis dysfunction with severe transvalvular regurgitation (n=1). Self-expanding supra-annular transcatheter heart valve (Valve-in-Valve-in-Valve configuration) was evaluated on Restoration of valve competence and clinical improvement. Implantation of a self-expanding supra-annular prosthesis in a valve-in-valve-in-valve configuration successfully restored valve competence and improved functional status to NYHA class I at 18 months.

synapsesocial.com/papers/69cf5ebd5a333a821460d5a4https://doi.org/10.7759/cureus.106304
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