Impact of High Implantation of Transcatheter Aortic Valve on Subsequent Conduction Disturbances and Coronary Access

Comparative Prognostic Value of Risk Factors for Predicting Pacemaker Implantation After Transcatheter Aortic Valve Replacement: A Systematic Review and Network Meta-Analysis

This study compares the prognostic value of risk factors for Permanent pacemaker implantation (PPI) following transcatheter aortic valve replacement (TAVR). PubMed, Embase, Scopus, and Cochrane Library databases were searched until November 2024 for studies reporting PPI incidence within 30 days post-TAVR. A random-effect model was used to pool risk ratios (RR) and standardized mean differences (SDM) for binary and continuous risk factors. Network meta-analysis estimated pooled risk differences (ΔRR) for binary predictors with male sex as the reference. Significant predictors were ranked based on their surface under the cumulative ranking curve (SUCRA) values. A total of 108 studies comprising 77,538 patients (14,560 requiring PPI) were included. Male sex (RR: 1.13), baseline atrial fibrillation (AF) (RR: 1.12), 2nd degree Mobitz I (RR: 5.16) and Mobitz II (RR: 2.30) atrioventricular blocks (AVB), 3rd degree AVB (RR: 13.46), left anterior (LAHB) (RR: 1.79) and posterior hemiblocks (LPHB) (RR: 2.57), bifascicular block (RR: 2.34), right bundle branch block (RBBB) (RR: 3.20) and intraprocedural AVB (RR: 4.15) were identified as predictors for PPI post-TAVR. The risk of PPI was higher with self-expandable valves (RR: 1.79), subclavian access (RR: 1.75), and 29 mm prostheses (RR: 1.33) compared to balloon-expandable valves, transfemoral access, and 23 mm prostheses. Network meta-analysis ranked 3rd degree AVB (SUCRA <0.01), Mobitz I AVB (SUCRA: 0.14), Mobitz II AVB (SUCRA: 0.33), intraprocedural AVB (SUCRA: 0.42), bifascicular block (SUCRA: 0.48), RBBB (SUCRA: 0.49) and LPHB (SUCRA: 0.54) as major predictors of PPI in descending order of significance. In conclusion, clinicians should closely monitor conduction abnormalities as key predictors of PPI following TAVR. Additionally, other risk factors such as subclavian access, self-expanding implantation, AF, large prosthesis diameter, and male sex should not be overlooked.

Coronary Artery Disease and Transcatheter Aortic Valve Replacement

Concomitant coronary artery disease (CAD) and severe aortic stenosis (AS) are frequently encountered in patients evaluated for transcatheter aortic valve replacement (TAVR). Invasive coronary angiography remains the mainstay for anatomical assessment of CAD, whereas coronary computed tomography angiography may be used in patients with a low pretest probability of CAD. Adjunctive functional evaluation of coronary lesions has proven safe in the presence of AS, but uncertainty remains over the impact of AS on the results of functional testing. For patients with CAD, revascularization of significant lesions (≥90% stenosis, fractional flow reserve ≤0.80) is associated with improved clinical outcomes compared to medical therapy. However, the optimal timing of percutaneous coronary intervention (PCI) remains unclear with no clear benefit to revascularization in advance of TAVR. When planning post-TAVR PCI, careful consideration should be given to the type of valve implanted, with short-frame valves having more favorable coronary access after TAVR. Planning for future coronary access is particularly relevant for patients who have either unrevascularized obstructive coronary lesions or unknown coronary anatomy in advance of TAVR. Moreover, post-TAVR PCI will likely increase, given the younger age profile of patients being treated and the trend to defer revascularization until after valve replacement.

Management of Acute Coronary Syndrome in Patients With Transcatheter Aortic Valve Replacement: A Review

Transcatheter aortic valve replacement (TAVR) has become a viable treatment option for patients with severe aortic stenosis among all risk subsets. As TAVR use becomes more prevalent and patients live longer with their transcatheter valve, an increasing number of these patients can be expected to present with ACS. Overall, there is a paucity of high-quality data detailing incidence, pathophysiology, and management of ACS in this subset. While most ACS cases post-TAVR are Type II myocardial infarctions (MI), the incidence of Type I MI and ST-elevation myocardial infarction is not negligible. Additionally, ACS in TAVR patients is associated with poor outcomes. While medical management is similar in this cohort to non-TAVR patients, procedural issues pose a unique challenge, especially as related to coronary access in the presence of valve prosthesis. Despite the proven benefit of invasive therapies in the management of ACS in non-TAVR patients, administrative databases suggest a lower utilization of invasive therapies in this cohort, which may highlight a disparity in care and potential for improvement. In this review, we summarize available data regarding the incidence, pathophysiology, and management of ACS in TAVR patients as well as strategies for coronary access post-TAVR.

High implantation of a balloon-expandable valve above the left ventricular outflow calcification improves the prosthetic valve function without increasing complications: a case series

Background

The initial outcomes of transcatheter aortic valve replacement in patients with left ventricular outflow tract calcification are poor. Furthermore, balloon-expandable transcatheter aortic valve replacement is associated with an increased risk of annular rupture, and self-expandable transcatheter aortic valve replacement is associated with worse post-operative residual paravalvular leakage grades. Therefore, developing an optimal method for transcatheter aortic valve replacement for patients with left ventricular outflow tract calcification is desirable.

Case summary

We present two cases of successful balloon-expandable transcatheter aortic valve replacement, wherein the transcatheter heart valve was implanted above the left ventricular outflow tract calcification to avoid annular rupture and paravalvular leakage, and one case each of balloon-expandable and self-expandable transcatheter aortic valve replacements, wherein the transcatheter heart valve was implanted at a normal height. Although annular rupture did not occur in any of the cases, more-than-mild paravalvular leakage persisted post-operatively in cases where the transcatheter heart valve was placed at a normal height.

Discussion

Annular rupture is more likely to occur in areas with high calcification at the joint than in noncalcified areas. Furthermore, the greater the calcification in the landing zone of the transcatheter heart valve, the more the paravalvular leakage persists. Therefore, high implantation of transcatheter heart valves above the left ventricular outflow tract calcification can be an effective method to avoid annular rupture and paravalvular leakage.

Hemodynamic effect of supra-annular implantation of SAPIEN 3 balloon expandable valve

The hemodynamic impact of the implantation depth for balloon-expandable valves is under-investigated, especially with higher implantation techniques. We assessed the hemodynamic performance of supra-annular SAPIEN 3 valve implantation. This retrospective study involved consecutive patients who underwent transcatheter aortic valve replacement (TAVR) using the SAPIEN 3. The device implantation depth and transcatheter heart valve (THV) leaflet-nadir position were angiographically analyzed, and supra-annular implantation was defined as a higher leaflet-nadir position than the original annular line. The Doppler hemodynamic status was evaluated at patient discharge. Among 184 patients, 120 (65%) underwent supra-annular implantation, and their mean implantation depth was significantly lower than that of intra-annular implantation (1.1 vs. 5.2 mm, p < 0.001). No patients developed valve embolization or coronary occlusion, and none required the TAV-in-TAV procedure. Two (1.6%) patients in the supra-annular implantation group had a mild or greater paravalvular leak. Echocardiography demonstrated that supra-annular implantation had better hemodynamic performance, showing a larger indexed effective orifice area (iEOA) compared with intra-annular implantation (1.09 vs. 0.97 cm2/m2, p < 0.01). There was a weak but negative correlation between the implantation depth and iEOA (r =  - 0.27, p < 0.01). Moderate or severe prosthesis-patient mismatch (PPM) was found in 35.9% of the intra-annular group and 9.2% of supra-annular of the supra-annular group (p < 0.01). In the multivariable analysis, supra-annular implantation was an independent predictor of better THV function (iEOA > 0.85). Supra-annular SAPIEN 3 implantation provides beneficial hemodynamic effects and reduces the PPM risk.

Lifetime management considerations to optimise transcatheter aortic valve implantation: a practical guide

Transcatheter aortic valve implantation (TAVI) is a safe and effective procedure for the treatment of aortic stenosis. With the recently broadened indications, there is a larger cohort of patients likely to outlive their first transcatheter heart valve (THV). This review discusses relevant lifetime planning considerations, focusing on the utility of preprocedural computed tomography imaging to help implanters future-proof their patients who are likely to outlive their first valve. The initial priority is to optimise the index procedure by maximising THV haemodynamic function and durability. This involves maximising the effective orifice area, minimising the risk of new pacemaker implantation, reducing paravalvular regurgitation, and preventing coronary obstruction and annular rupture. In patients requiring a second valve procedure, a significant proportion will require a TAVI-in-TAVI, and implanters should consider the key priorities for a redo procedure, including the increased risks of patient-prosthesis mismatch and conduction abnormalities, promoting coronary reaccessibility, and preventing coronary obstruction and sinus sequestration. Careful planning can identify potential hurdles as well as predict the feasibility and likely outcomes of redo-TAVI, to help individualise care over the lifetime of each patient.

Conduction Disturbances After Transcatheter Aortic Valve Replacement: An Update on Epidemiology, Preventive Strategies, and Management

Conduction disturbances (CDs) are common after transcatheter aortic valve replacement. Continuous improvements in preprocedural planification, implant techniques, and device design have markedly reduced periprocedural complications. However, CDs rate remains in the double-digit range. Because CDs after TAVR are associated with poorer outcomes, seeking a reduction in their occurrence is paramount. Several nonmodifiable and modifiable factors are associated with an increased risk of CDs. Previous right bundle branch block has been shown to have a strong association with pacemaker implant after TAVR. Among the modifiable factors, a lower implantation depth seems to be associated with a higher risk of CDs, and several implant strategies aiming to obtain a higher implant depth have shown promising results. This literature review provides a detailed description of updated evidence about the epidemiology, impact, and preventive and management strategies of CDs after TAVR. Also, based on these updated data, a fast-track protocol CDs management is proposed.

Decision-Making Approach to the Treatment of Young and Low-Risk Patients With Aortic Stenosis

Over a decade of randomized controlled trial data demonstrate excellent outcomes with transcatheter aortic valve replacement or surgical aortic valve replacement for patients with symptomatic severe aortic stenosis regardless of surgical risk. The 2020 American College of Cardiology/American Heart Association guidelines recommend both options for low-risk AS patients aged 65 to 80 years. However, the fastest growing population of patients receiving transcatheter aortic valve replacement in the United States is <65 years old, with little data to support the practice. The American College of Cardiology's Cardiac Surgery Team Section Leadership and Interventional Cardiology Councils, a multidisciplinary collaboration of cardiologists and cardiac surgeons, sought to summarize the relevant data into a decision-making tool for heart valve teams. A literature review was completed, and guidelines, randomized controlled trials, and large observational studies were summarized into a pragmatic decision-making approach to treating young and low-risk patients with AS.

[The role of implant projection in optimizing transcatheter aortic valve implantation]

Severe aortic stenosis is the most frequent valve condition requiring surgery, and its incidence is increasing yearly. Transcatheter aortic valve implantation (TAVI) is the first-line treatment for patients at all levels of surgical risk. Nevertheless, modifications to the procedure often appear to improve clinical outcomes. A major concern after TAVI is the higher rate of permanent pacemaker implantation (PPMI) compared with surgical valve replacement. Optimal implantation depth is crucial to reduce the burden of PPMI without causing serious complications such as valve embolization. The classic implantation technique, where the 3 cusps are aligned in the same plane, has been modified to a cusp overlap projection by isolating the noncoronary cusp and superimposing the left and right cusps. This simple modification provides optimal visualization during deployment and helps to achieve the desired implant depth to reduce conduction disturbances and PPMI. Another limitation after TAVI is coronary reaccess due to the frame of the transcatheter valve obstructing the coronary ostia. Commissural alignment of the prostheses with the native valve may facilitate selective cannulation of the coronary arteries after this procedure. This review will discuss the techniques and supporting evidence for these modifications to the deployment and implant projection methods, and how they can improve TAVI outcomes.

Impact of Accidental High or Low Implantation Depth on Peri-Procedural Outcomes after Implantation with the Self-Expanding ACURATE neo2

Background: Precise implantation could play a crucial role in the technical success of transcatheter aortic valve replacement (TAVR) for some prostheses. The impact of an accidental implantation depth (ID) outside the recommended range has not been assessed for the ACURATE neo2 (NEO2). Methods: Data from 1839 patients with severe native aortic stenosis treated with the NEO2 prosthesis were evaluated. We compared the results of prostheses implanted in an ID both inside and outside the recommendations. The outcome assessment followed the Valve Academic Research Consortium-3 criteria. Results: Patients were retrospectively divided into high (<3 mm; n = 412), optimal (3-7 mm; n = 1236), and low (>7 mm; n = 169) implantations. Technical success (94.7% vs. 94.7% vs. 91.7%, p = 0.296) and device success were high (90.1% vs. 89.3% vs. 84.6%, p = 0.112) without differences between groups. Rates of relevant paravalvular regurgitation (PVL; >mild or VinV due to PVL) were comparable (1.2% vs. 1.8% vs. 1.2%, p = 0.759). Even when hemodynamics were superior in the high-implantation group, with greater iEOA (1.01 cm2/m2 vs. 0.95 cm2/m2 vs. 0.92 cm2/m2, p < 0.001), spontaneous embolization or after post-dilatation was more common. Low implantation was associated with a higher rate of associated pacemaker implantation (PPI) (6.1% vs. 8.8% vs. 14.8%, p = 0.001). Conclusions: Implantation with the ACURATE neo2 showed excellent hemodynamic results, including low gradients and a small number of relevant PVL, in line with a high technical success rate that was irrespective of the ID. A favorable outcome can also be achieved in accidental low or high positions. Low implantation was associated with a higher rate of associated pacemaker implantation. Deliberately high implantation should be avoided due to the risk of embolization.

Prognosis and Predictor Factors of Permanent Pacemaker Implantation after Transcatheter Aortic Valve Replacement: A Retrospective Analysis of the Post-Transcatheter Aortic Replacement Clairval Hospital Registry

Background/Objectives: Despite procedural improvements, post-transcatheter aortic valve replacement (TAVR) conduction disorders remain high. Analyzing the data from a monocentric TAVR registry, this study aims to determine predictive factors for PPI (primary outcome), the indication for PPI, and long-term outcomes among these patients (secondary outcomes). Methods: Conducted at Clairval Hospital in Marseille, France, this retrospective study included all consecutive patients from June 2012 to June 2019. Clinical, electrocardiographic, echocardiographic, and procedural data were collected, with outcomes assessed annually. Logistic regression identified PPI predictors and survival analyses were performed. Results: Of the 1458 patients initially considered, 1157 patients were included. PPI was needed in 21.5% of patients, primarily for third-degree atrioventricular block (46.4%). Predictor factors for PPI included baseline right bundle branch block (ORadj 2.49, 95% CI 1.44 to 4.30; p = 0.001), longer baseline QRS duration (ORadj 1.01, 95% CI 1.00 to1.02, p = 0.002), and self-expandable valves (ORadj 1.82, 95% CI, 1.09 to 3.03; p = 0.021). Seven-year estimated mortality was higher in PPI (43.3%) vs. non-PPI patients (30.9%) (log rank p = 0.048). PPI was an independent predictive factor of death (ORadj 2.49, 95% CI 1.4 to 4.3; p = 0.002). Conclusions: This study reveals elevated rates of PPI post-TAVR associated with increased mortality. These results underscore the pressing necessity to refine our practices, delineate precise indications, and enhance the long-term prognosis for implanted patients.

The Application of Precision Medicine in Structural Heart Diseases: A Step towards the Future

The personalized applications of 3D printing in interventional cardiology and cardiac surgery represent a transformative paradigm in the management of structural heart diseases. This review underscores the pivotal role of 3D printing in enhancing procedural precision, from preoperative planning to procedural simulation, particularly in valvular heart diseases, such as aortic stenosis and mitral regurgitation. The ability to create patient-specific models contributes significantly to predicting and preventing complications like paravalvular leakage, ensuring optimal device selection, and improving outcomes. Additionally, 3D printing extends its impact beyond valvular diseases to tricuspid regurgitation and non-valvular structural heart conditions. The comprehensive synthesis of the existing literature presented here emphasizes the promising trajectory of individualized approaches facilitated by 3D printing, promising a future where tailored interventions based on precise anatomical considerations become standard practice in cardiovascular care.

Redo-TAVR Feasibility After SAPIEN 3 Stratified by Implant Depth and Commissural Alignment: A CT Simulation Study

BACKGROUND

Redo-transcatheter aortic valve replacement (TAVR) can pin the index transcatheter heart valve leaflets open leading to sinus sequestration and restricting coronary access. The impact of initial implant depth and commissural alignment on redo-TAVR feasibility is unclear. We sought to determine the feasibility of redo-TAVR and coronary access after SAPIEN 3 (S3) TAVR stratified by implant depth and commissural alignment.

METHODS

Consecutive patients with native valve aortic stenosis were evaluated using multidetector computed tomography. S3 TAVR simulations were done at 3 implant depths, sizing per manufacturer recommendation and assuming nominal expansion in all cases. Redo-TAVR was deemed unfeasible based on valve-to-sinotubular junction distance and valve-to-sinus height <2 mm, while the neoskirt plane of the S3 transcatheter heart valve estimated coronary access feasibility.

RESULTS

Overall, 1900 patients (mean age, 80.2±8 years; STS-PROM [Society of Thoracic Surgeons Predicted Risk of Operative Mortality], 3.4%) were included. Redo-TAVR feasibility reduced significantly at shallower initial S3 implant depths (2.3% at 80:20 versus 27.5% at 100:0, P<0.001). Larger S3 sizes reduced redo-TAVR feasibility, but only in patients with a 100:0 implant (P<0.001). Commissural alignment would render redo-TAVR feasible in all patients, assuming the utilization of leaflet modification techniques to reduce the neoskirt height. Coronary access following TAV-in-TAV was affected by both index S3 implant depth and size.

CONCLUSIONS

This study highlights the critical impact of implant depth, commissural alignment, and transcatheter heart valve size in predicting redo-TAVR feasibility. These findings highlight the necessity for individualized preprocedural planning, considering both immediate results and long-term prospects for reintervention as TAVR is increasingly utilized in younger patients with aortic stenosis.

Transcatheter aortic valve replacement in heart failure

Patients with severe aortic stenosis (AS) may develop heart failure (HF), the presence of which has traditionally been deemed as a final stage in AS progression with poor outcomes. The use of transcatheter aortic valve replacement (TAVR) has become the preferred therapy for most patients with AS and concomitant HF. With its instant afterload reduction, TAVR offers patients with HF significant haemodynamic benefits, with corresponding changes in left ventricular structure and improved mortality and quality of life. The prognostic covariates and optimal timing of TAVR in patients with less than severe AS remain unclear. The purpose of this review is to describe the association between TAVR and outcomes in patients with HF, particularly in the setting of left ventricular systolic dysfunction, acute HF, and right ventricular systolic dysfunction, and to highlight areas for future research.

Risk of Sinus Sequestration During Redo Transcatheter Aortic Valve Implantation: The Prevalence, Predictors, and Risk Stratification

The number of patients who underwent transcatheter aortic valve implantation (TAVI) with the potential for reintervention is steadily increasing; however, there is a risk of sinus sequestration (SS) during a redo TAVI. The prevalence, predictors, and risk stratification of the risk for SS remain uncertain. We analyzed computed tomography acquired from 263 patients who underwent TAVI between 2021 and 2022: balloon-expandable valve (BEV) (71%) and self-expandable valve (SEV) (29%). Patients were considered at risk for SS if they met the following: (1) BEV frame > sinotubular junction (STJ) or SEV neocommissure greater than the STJ and (2) valve-to-STJ <2 mm. The risk of left, right, and any SS in 51%, 50%, and 65%, respectively, did not differ between BEV and SEV. The predictors of any SS were the height of the left and right coronary cusp (odds ratio [OR] 0.81 and 0.71, cutoff 18.6 and 19.2 mm, respectively) and STJ minus the annulus diameter (OR 0.65, cutoff 3.7 mm) in BEV, and STJ diameter (OR 0.47, cutoff 27.6 mm) in SEV. The number of predictors stratified the risk of any SS: low risk with BEV at 0 predictors (14% at risk of SS), intermediate risk at 1 predictor (65%), high risk at 2 or 3 predictors (81% and 95%), and low risk with SEV at 0 predictors (33%) versus high risk at 1 predictor (91%). In conclusion, 2/3 of patients who underwent TAVI were at risk of SS. The height of the coronary cusp and the STJ diameter were associated with and adequately stratified the risk of SS.

Assessing Potential Risks of Future Redo Transcatheter Aortic Valve Replacement in Asian Patients

Background

In the Asian cohort, data are limited on the risk for coronary obstruction due to sinus of Valsalva (SOV) sequestration in redo transcatheter aortic valve replacement (TAVR) procedures.

Objectives

The aim of this study was to assess the potential risk for coronary obstruction in simulated redo TAVR in Asian patients.

Methods

Post-TAVR computed tomographic data from 788 patients who received balloon-expandable (BE) SAPIEN 3 transcatheter aortic valves (TAVs) and 334 patients who received self-expanding (SE) Evolut R or Evolut PRO TAVs were analyzed. The risk for coronary obstruction due to SOV sequestration in redo TAVR, defined as the TAV commissure level above the sinotubular junction (STJ) and a TAV-to-STJ distance <2.0 mm in each coronary sinus, was retrospectively evaluated.

Results

The potential risks for coronary obstruction due to SOV sequestration at 1 or both coronary arteries were identified in 52.1% of the BE TAV group and 71.3% of the SE TAV group (P < 0.001). After adjusting for multiple covariates, STJ diameter, STJ height, TAV oversizing degree by area, and implantation depth were independently associated with SOV sequestration risk in the BE TAV group, whereas STJ diameter and implantation depth were independently associated with SOV sequestration risk in the SE TAV group.

Conclusions

Coronary obstruction due to SOV sequestration in redo TAVR may occur in a substantial number of Asian patients. This finding suggests the importance of considering the structural feasibility of future redo TAVR when implanting the first TAV, especially in Asian patients with long life expectancy.

Transcatheter Aortic Valve Implantation and Conduction Disturbances: Focus on Clinical Implications

Transcatheter aortic valve implantation (TAVI) is an established alternative to surgery in patients with symptomatic severe aortic stenosis and has expanded its indications to even low-surgical-risk patients. Conduction abnormalities (CA) and permanent pacemaker (PPM) implantations remain a relatively common finding post TAVI due to the close proximity of the conduction system to the aortic root. New onset left bundle branch block (LBBB) and high-grade atrioventricular block are the most commonly reported CA post TAVI. The overall rate of PPM implantation post TAVI varies and is related to pre- and intra-procedural factors. Therefore, when screening patients for TAVI, Heart Teams should take under consideration the various anatomical, pathophysiological and procedural conditions that predispose to CA and PPM requirement after the procedure. This is particularly important as TAVI is being offered to younger patients with longer life-expectancy. Herein, we highlight the incidence, predictors, impact and management of CA in patients undergoing TAVI.

Feasibility of Redo-Transcatheter Aortic Valve Replacement in Sapien Valves Based on In Vivo Computed Tomography Assessment

BACKGROUND

Our aim was to assess the feasibility of repeat transcatheter aortic valve (TAV) replacement for degenerated Sapien3 (S3) prostheses by simulating subsequent implantation of S3 or Evolut, using in vivo computed tomography-based sizing and the impact on coronary and patient-prosthesis mismatch risks.

METHODS

Computed tomography scans from 356 patients with prior S3 TAV replacement implantation were analyzed. The in vivo sizing for second TAV based on averaged area of 3 levels of outflow, mid (narrowest) and inflow, was compared with in vitro recommendations, that is, same size as index S3 for second S3 and 1 size larger for Evolut. Risks of coronary obstruction and patient-prosthesis mismatch were determined by valve-to-aorta distance and estimated effective orifice area, respectively.

RESULTS

Overall, the majority of patients (n=328; 92.1%) had underexpanded index S3 with an expansion area of 94% (91%-97%), leading to significant differences in size selection of the second TAV between in vivo and in vitro sizing strategies. Expansion area <89% served as a threshold, resulting in 1 size smaller than the in vitro recommendations were selected in 45 patients (13%) for S3-in-S3 and 13 (4%) for Evolut-in-S3, while the remaining patients followed in vitro recommendations (P<0.01, in vivo versus in vitro sizing). Overall, 57% of total patients for S3-in-S3 simulation and 60% for Evolut-in-S3 were considered low risk for coronary complications. Deep index S3 implantation (odds ratio, 0.76 [interquartile range, 0.67-0.87]; P<0.001) and selecting Evolut as the second TAV (11% risk reduction in intermediate- or high-risk patients) reduced coronary risk. Estimated moderate or severe patient-prosthesis mismatch risk was 21% for S3-in-S3 and 1% for Evolut-in-S3, assuming optimal expansion of the second TAV.

CONCLUSIONS

Redo-TAV replacement with S3-in-S3 and Evolut-in-S3 could be feasible with low risk to coronaries in ≈60% of patients, while the remaining 40% will be at intermediate or high risk. The feasibility of redo-TAV replacement is influenced by sizing strategy, type of second TAV, native annular anatomy, and implant depth.