Transcatheter aortic valve replacement (TAVR) has created a growing population of patients who require redo-TAVR (TAV-in-TAV) for structural valve deterioration. Short-frame balloon-expandable valves implanted within failed short- or tall-frame transcatheter valves ("short-in-short" and "short-in-tall") pose specific challenges, including coronary risk assessment, valve sizing, anchoring, and preservation of coronary access. Under the auspices of the Heart and Valve Collaboratory, an international multidisciplinary panel of experts reviewed bench and clinical data and synthesized contemporary best practices into a pragmatic workflow for redo-TAVR. This document standardizes key anatomic definitions, outlines computed tomography-based strategies for in vivo sizing, and details recommended approaches to predilatation, deployment techniques, and postdilatation. By harmonizing terminology and stepwise planning across imaging, interventional, and surgical teams, this document aims to simplify procedural decision-making and improve safety, coronary preservation, and hemodynamic outcomes in patients undergoing short-in-short and short-in-tall TAV-in-TAV procedures.

As transcatheter aortic valve replacement (TAVR) expands rapidly into younger low-risk cohorts with long life expectancy, increasing numbers of patients will outlive their valves and present with bioprosthetic valve failure requiring treatment. Age, comorbidities, and the complexity of surgical explantation will make redo TAVR the preferred treatment option in the vast majority of patients. However, redo TAVR poses specific anatomical challenges, including an elevated risk of coronary artery obstruction, the preservation of coronary access, and optimization of hemodynamic outcomes and long-term durability, though few data exist to guide clinicians in the optimal procedural approach. Meanwhile, surgical explantation and valve replacement will remain a vital option in specific groups, including those with endocarditis and with anatomical features that prohibit redo TAVR.This review article provides a detailed exposition of the challenges of both transcatheter and surgical treatment of transcatheter aortic valve failure, recommended strategies for diagnosis, preprocedural planning and procedural execution to deliver safe and effective outcomes, and a summary of the current evidence base in this growing field.

The extension of transcatheter aortic valve replacement (TAVR) to younger patients with longer life expectancy has driven a shift in focus toward procedural optimization, with the goals of maximal clinical improvement, durable outcomes, maintained coronary access, and avoidance of permanent pacemaker implantation. A TAVR CODE framework including 4 key fluoroscopic parameters-coaxiality, orientation, depth, and expansion-has recently been proposed to standardize the intraprocedural evaluation of optimal transcatheter heart valve (THV) implantation. Systematic implementation of these concepts during TAVR is expected to improve valve performance and durability. This is hypothesized to improve afterload reduction, enhance left ventricular reverse remodeling, and confer increased and longer lasting clinical benefits. To date, procedural strategies to optimize TAVR outcomes have been largely based upon expert opinion, supported predominantly by mechanistic and retrospective studies. Ongoing randomized trials are evaluating the effects of systematic pre- and postdilatation during TAVR, the impact of same-volume double-tap techniques with balloon-expandable valves, and the effectiveness of different commissural alignment techniques. Meanwhile, intravascular ultrasound is under investigation as a tool to evaluate THV expansion to guide postdilatation, while technical consistency may be improved by innovative THV designs that promote symmetrical expansion, better fluoroscopic visualization, and robotic insertion systems using artificial intelligence. In this article, we detail the possible impact of implementing the TAVR CODE framework on THV function, durability, and clinical outcomes, and provide an expert perspective on procedural strategies to achieve optimal index TAVR outcomes, including management frameworks and position statements according to contemporary best practices.

BACKGROUND:The JenaValve Trilogy Transcatheter Heart Valve System (Trilogy) is a CE-marked transcatheter aortic valve replacement device designed for the treatment of symptomatic aortic regurgitation. Despite its unique indication, data from large cohorts remain limited. This study aimed to evaluate procedural characteristics and clinical outcomes in all-comers patients with symptomatic aortic regurgitation undergoing transfemoral transcatheter aortic valve replacement with the Trilogy valve. METHODS:This multicenter retrospective analysis included patients with symptomatic aortic regurgitation who underwent Trilogy implantation between June 2021 and June 2025 at 8 European centers. Baseline, procedural, and follow-up data were collected according to local protocols, and outcomes were defined per VARC-3 (Valve Academic Research Consortium-3). RESULTS:A total of 363 patients (median age, 81 years [interquartile range, 75-84]; 45% female patients; median European System for Cardiac Operative Risk Evaluation II, 3.4%; median left ventricular ejection fraction, 50%) were included. Transfemoral access was used in 359 (99%), and technical success was achieved in 98%. Valve embolization occurred in 5 patients: 2 managed with a second valve, 2 surgically, and 1 required valve-in-valve reintervention. Two additional technical failures involved hemodynamic instability and a vascular complication. At discharge, 86% had none or trace leakage, and the mean transvalvular gradient was 4 mm Hg. Permanent pacemaker implantation was required in 22%. In-hospital mortality was 0.3%. At 30 days, functional status had improved markedly, with 88% of patients in New York Heart Association class I or II. Kaplan-Meier estimated all-cause mortality at 6 months, 1, 2, and 3 years was 4.1%, 7.0%, 15.8%, and 25.9%, respectively, among patients with available follow-up. CONCLUSIONS:In this large analysis, transfemoral transcatheter aortic valve replacement with the Trilogy valve demonstrated high procedural success and favorable hemodynamic valve performance. These findings are encouraging and suggest a potential role for the Trilogy valve in patients with symptomatic aortic regurgitation who are unsuitable for surgery.

BACKGROUND:Transcatheter aortic valve (TAV) failure may require redo transcatheter aortic valve replacement (redo-TAVR). The multiple layers of metal after redo-TAVR may jeopardize coronary artery patency and accessibility and result in prosthesis-patient mismatch. Dedicated software may use multi-slice computed tomography (MSCT) imaging to simulate TAV deployment relative to the prior TAV and the individual's anatomy and predict coronary accessibility and TAV expansion. AIM:We aimed to validate redo-TAVR simulations created in FEops HEARTguide. METHODS:This multicenter observational study included redo-TAVR patients who had MSCT imaging available at baseline, after index-TAVR and after redo-TAVR. Patient-specific redo-TAVR simulations were created. Simulated valve-to-aorta distances (a proxy for coronary accessibility), neoskirt height, TAV expansion at multiple frame levels, and residual valve area after redo-TAVR were compared to follow-up MSCT. RESULTS:Among 25 patients, HEARTguide simulations of valve-to-coronary (VTC) distance (left VTC 6.0 ± 2.2 vs. 6.4 ± 2.3 mm, ICC = 0.856, p < 0.001; right VTC 5.8 ± 1.9 vs. 5.6 ± 1.9 mm, ICC = 0.740, p < 0.001) showed good agreement while valve-to-sinotubular-junction (VTSTJ) distance showed moderate agreement with follow-up MSCT (left VTSTJ 2.5 ± 1.8 vs. 3.3 ± 1.8 mm, ICC = 0.614, p = 0.004; right VTSTJ 2.8 ± 1.8 vs. 2.9 ± 1.2 mm, ICC = 0.613, p = 0.003). Redo-TAVR frame expansion simulations (mean frame area 434.8 ± 141.6 vs. 401.6 ± 142.9 mm, ICC = 0.930, p < 0.001; 393.5 ± 63.2 vs. 383.1 ± 82.5 mm, ICC = 0.822, p < 0.001, respectively) and simulations of residual valve area after redo-TAVR showed good agreement for self-expanding and balloon-expandable TAV (407.8 ± 67.8 vs. 389.6 ± 50.4 mm, ICC = 0.837, p < 0.001; 358.0 ± 66.1 vs. 336.1 ± 79.9 mm, ICC = 0.823, p < 0.001). CONCLUSIONS:In this pilot study, MSCT-derived simulations of redo-TAVR provided accurate insights into coronary accessibility, TAV expansion, and residual valve area.

INTRODUCTION AND OBJECTIVES:In patients with tricuspid aortic valve stenosis, the coexistence of aortic regurgitation (AR) at baseline has been associated with improved outcomes following transcatheter aortic valve implantation (TAVI). However, its prognostic impact in patients with bicuspid aortic valve (BAV) stenosis remains unknown. METHODS:We enrolled consecutive patients with severe Sievers type 1 BAV stenosis undergoing TAVI at 24 international centers. Patients were stratified into 2 groups according to baseline AR severity: pure BAV stenosis (ie, no or mild AR) and mixed BAV disease (ie, moderate or severe AR). Clinical outcomes were compared using adjusted Cox models. The primary endpoint was major adverse events (MAE), defined as a composite of all-cause death, cerebrovascular events, or hospitalization for heart failure. RESULTS:A total of 956 patients were included, of whom 134 (14%) had mixed BAV disease and 822 (86%) had pure BAV stenosis. At a median follow-up of 1.2 [0.4-2.2] years, patients with mixed BAV disease had a lower risk of MAE compared with those with pure BAV stenosis (9.0% vs 17.5%; adjusted hazard ratio [HRadj], 0.47; 95%CI, 0.25-0.85; P=.013), mainly driven by a significantly lower risk of all-cause death (6.0% vs 12.0%; HRadj, 0.44; 95%CI, 0.21-0.92; P=.029). CONCLUSIONS:Among patients with Sievers type 1 BAV stenosis undergoing TAVI, those with mixed BAV disease had a lower risk of MAE than those with pure BAV stenosis.

Abstract Background Transcatheter heart valve (THV) underexpansion is associated with haemodynamic valve deterioration. Double inflation of balloon-expandable valves using the delivery balloon with unchanged volume (double-tap) may improve THV expansion, while minimizing the risk of complications. Aims To evaluate the efficacy of double-tap after transcatheter aortic valve implantation (TAVI) with SAPIEN-3 Ultra RESILIA (S3UR) valves. Methods This observational study included consecutive patients who underwent TAVI for severe native aortic stenosis and had same-volume double-tap, from November 2024 to September 2025. THV expansion and deformation were assessed fluoroscopically before and after double-tap after appropriate calibration. Thirty-day clinical outcomes were reported. Results Of 113 patients who underwent TAVI with same-volume double-tap (mean age: 79.3 ± 7.3 years, 26.5% female, 13.3% bicuspid anatomy), the median THV expansion before double-tap, at the inflow, mid-portion, and outflow was 88.6% (IQR: 86.4–90.4%), 80.1% (IQR: 77.3–82.3%), and 90.1% (IQR: 88.4–90.9%) respectively, and after double-tap increased to 96.4% (IQR: 94.6–98.4%), 90.8% (IQR: 88.6–92.9%), and 97.6% (IQR: 96.3–99.0%) (all P < .001). The largest increase in expansion following double-tap occurred in the THV mid-portion (median: 10.6% [IQR: 9.8–11.6%]). Multivariable predictors of the extent of minimum expansion improvement following double-tap were bicuspid anatomy (P = .005) and aortic valve calcium volume of >385 mm3 (median) (P = .046). The median THV deformation index decreased from 1.05 (IQR: 1.04–1.07) to 1.03 (IQR: 1.02–1.04) after double-tap (P < .001). Thirty-day mortality rate was 0.9%. Conclusion Routine double-tap post-dilatation of balloon-expandable valves improves THV expansion and frame deformation, without any clear safety signal. Bicuspid anatomy and aortic valve calcium burden predicted the extent of expansion improvement.

BACKGROUND:Evidence regarding prosthesis-patient mismatch (PPM), measured (mPPM), and predicted (pPPM), after transcatheter aortic valve replacement in bicuspid aortic valve stenosis remains limited. This study sought to evaluate the incidence, predictors, and prognostic implications of mPPM and pPPM in patients with Sievers type 1 bicuspid aortic valve undergoing transcatheter aortic valve replacement. METHODS:The AD-HOC registry is a retrospective, multicenter study including 781 patients with severe aortic stenosis and bicuspid aortic valve treated with transcatheter aortic valve replacement between 2016 and 2023 across 24 centers. PPM was defined according to Valve Academic Research Consortium-3 criteria. The primary outcome was all-cause mortality. RESULTS:Moderate-to-severe mPPM was more frequent than pPPM (22% versus 8%; P<0.001). Balloon-expandable valves were independently associated with both mPPM and pPPM, while smaller valve size and supra-annular sizing predicted only pPPM. During a mean follow-up of 621±470 days, neither mPPM nor pPPM was associated with mortality in the overall cohort. Among patients with a small annulus (≤430 mm2; n=145), pPPM occurrence was significantly higher (19% versus 5.5%; P<0.001) and was associated with increased all-cause mortality, but not with cardiovascular mortality. CONCLUSIONS:In patients with Sievers type 1 bicuspid aortic valve undergoing transcatheter aortic valve replacement, pPPM occurred less frequently than mPPM and was predominantly driven by anatomic characteristics and sizing strategies. Although pPPM was associated with increased all-cause mortality among patients with small annuli, this association did not extend to cardiovascular mortality and should be considered hypothesis-generating. Further prospective investigations are warranted to better delineate the impact of anatomic constraints on clinical outcomes in this anatomically challenging subset.

Objectives We examined the utility of quality indicators (QIs) for transcatheter aortic valve implantation (TAVI) in the assessment of TAVI care quality and variation in practice.Design We performed a retrospective population-level cohort study in Ontario, Canada, where all residents receive publicly funded universal medical care. We examined the association between QI attainment and outcomes using multivariable hierarchical logistic models. We used median ORs to understand if variation in clinical outcomes between hospitals was attributable to variation in QI attainment.Setting We used all-comer registry data from the provincial CorHealth registry in Ontario, with linkage to administrative datasets using unique patient encoded identifiers.Participants TAVI recipients between 2018 and 2023 in Ontario, Canada.Intervention We derived a unique set of QIs from internationally agreed ones.Primary and secondary outcome measures The primary endpoint was a composite of all-cause mortality or rehospitalisation at 1 year from the date of TAVI.Results Data from 9748 TAVI procedures were included between 2018 and 2023. We identified five feasible QIs, the majority of which had high compliance and minimal variation; the lone exception was the performance of transfemoral TAVI without general anaesthesia (median 0.87; IQR 0.78–0.93). Adherence to QIs was associated with a reduction in the composite endpoint. The strongest association was observed with multidisciplinary heart team involvement (defined as the presence of an interventional cardiologist and a cardiac surgeon) in the TAVI procedure (OR 0.67, 95% CI 0.50 to 0.90, p=0.007), the performance of transfemoral TAVI without general anaesthesia (OR 0.80, 95% CI 0.71 to 0.91, p<0.0004) and the utilisation of the transfemoral access (OR 0.84, 95% CI 0.69 to 1.04, p=0.10). However, variation in clinical outcomes following TAVI between hospitals was not attributable to variation in QI attainment. Falsification analysis suggests substantial residual confounding.Conclusions We developed a feasible set of QIs for TAVI and validated these QIs using routinely collected data from a large all-comer registry in Ontario. We have identified overall high quality of care for TAVI, but with some variation in practice, which in part is attributable to differences in patient factors. Our work suggests that QIs can inform quality improvement efforts by prompting future work into discretionary versus non-discretionary variation.

Evidence regarding transcatheter aortic valve implantation (TAVI) in young (≤ 75 years) low-risk patients with bicuspid aortic valve (BAV) stenosis deemed unsuitable for surgery is scarce. To investigate in-hospital and follow-up outcomes in this population compared with older or higher-risk patients. This retrospective international registry included 980 patients with severe BAV stenosis undergoing TAVI, stratified in: Group I, < 69 years and Society of Thoracic Surgeons predicted mortality (STS-PROM) < 4 (N = 113); Group II, 69–75 years and STS-PROM < 4 (N = 173); Group III, > 75 years or STS-PROM ≥ 4 (N = 694). Endpoints included technical success, 30-day device success and safety, transcatheter heart valve (THV) function during follow-up, survival and freedom from transient ischemic attack (TIA)/stroke or heart failure hospitalization. Technical success was comparable (Group I: 94.7

BACKGROUND:Comparative data between self-expanding Navitor (NAV) and balloon-expandable SAPIEN 3 Ultra (ULTRA) transcatheter heart valves (THVs) in patients with small aortic annuli are lacking. AIMS:This study sought to evaluate outcomes of transcatheter aortic valve implantation (TAVI) using the intra-annular NAV and the ULTRA THVs in severe aortic stenosis patients with small annuli. METHODS:Patients with an aortic annulus area ≤430 mm2 undergoing TAVI with either NAV or ULTRA from the NAVULTRA registry were included. Propensity-matched analysis was performed for adjustment. Primary endpoints included 1-year mortality, a composite endpoint (all-cause mortality, disabling stroke, or heart failure hospitalisation), and 30-day device-oriented outcomes (severe prosthesis-patient mismatch, moderate or greater paravalvular leak [PVL], mean gradient ≥20 mmHg). RESULTS:Among 1,617 patients, 524 propensity score-matched pairs were analysed. At 1 year, all-cause mortality was 8.8% with NAV versus 9.0% with ULTRA (adjusted p=0.585), and the composite endpoint occurred in 11.3% versus 11.8%, respectively (adjusted p=0.149). The device-oriented endpoint favoured NAV compared to ULTRA (6.0% vs 29.3%; adjusted p<0.01), with a lower residual transvalvular gradient (7.3 mmHg vs 12.7 mmHg; adjusted p<0.01), and reduced incidence of any prosthesis-patient mismatch (odds ratio 0.27, 95% confidence interval: 0.18-0.43; adjusted p<0.01). However, NAV was associated with higher rates of mild paravalvular leak (NAV 33.5% vs ULTRA 23.2%; adjusted p<0.05) and permanent pacemaker implantation (PPI; NAV 20.1% vs 11.9% ULTRA; adjusted p<0.01). CONCLUSIONS:In patients with small aortic annuli, TAVI with both NAV and ULTRA provided comparable 1-year clinical outcomes, but NAV showed better haemodynamic performance at the cost of higher rates of mild PVL and PPI.

As Transcatheter Aortic Valve Replacement (TAVR) expands rapidly into younger low-risk cohorts with long life-expectancy, increasing numbers of patients will outlive their valves, and will present with bioprosthetic valve failure requiring treatment. Age, co-morbidities, and the complexity of surgical explantation will make redo TAVR the preferred treatment option in the vast majority of patients. However, redo TAVR poses specific anatomical challenges, including an elevated risk of coronary artery obstruction, the preservation of coronary access, and optimisation of hemodynamic outcomes and long-term durability, while few data exist to guide clinicians in the optimal procedural approach. Meanwhile, surgical explantation and valve replacement will remain a vital option in specific groups, including those with endocarditis and with anatomical features that prohibit redo TAVR.This review article provides a detailed exposition of the challenges of both transcatheter and surgical treatment of TAV failure, recommended strategies for diagnosis, pre-procedural planning and procedural execution to deliver safe and effective outcomes, and a summary of the current evidence base in this growing field.

BACKGROUND:A minimalist approach to transcatheter aortic valve replacement (TAVR) has accompanied the increase in TAVR procedures worldwide. Comprehensive evidence regarding the safety of non-anesthetist-led conscious sedation for TAVR is lacking. AIMS:We aimed to evaluate the outcomes of patients undergoing TAVR with non-anesthetist-led conscious sedation. METHODS:This retrospective analysis included consecutive patients who underwent percutaneous transfemoral TAVR with non-anesthetist-led conscious sedation, from March 2018 to 2025, in a single high-volume center. Thirty-day outcomes were assessed. RESULTS:Of 2854 patients who underwent TAVR, 2000 (70.1%) had non-anesthetist-led conscious sedation (age: 80.7 ± 6.5 years, 42.1% female). The annual proportion of non-anesthetist-led conscious sedation procedures increased from 37% (2018-2019) to 81% (2024-2025). Fentanyl was administered to 1986 (99.3%) patients (median: 75 mcg [IQR: 50-100]) and Midazolam to 945 (47.3%) patients (median: 1.5 mg [IQR: 1.0-2.0]). Mean procedural duration was 81.3 ± 67.7 min. Emergency anesthetic support was required for 53 (2.7%) patients, due to: vascular access complications (n = 15), cardiac arrest (n = 14), annular rupture/aortic dissection (n = 9), profound hypotension (n = 8), agitation (n = 4), ventricular perforation (n = 2) and reduced consciousness (stroke) (n = 1). Conversion to general anesthesia was required for 24 (1.2%) patients. Emergency bail-out surgery (cardiac/vascular) was undertaken in 15 patients (0.75%). Among the 2000 patients, 30-day mortality was 1.3%, and VARC-3 technical success, device success, and early safety were achieved in 97.2%, 92.7%, and 78.9% of patients, respectively. CONCLUSIONS:Non-anesthetist-led conscious sedation can be delivered safely in most patients undergoing percutaneous transfemoral TAVR. The need for emergency anesthetic support is low.

BACKGROUND:Valve durability is a key consideration as the patient population eligible for transcatheter aortic valve implantation (TAVI) expands to include lower-risk and younger individuals who are expected to live many years after the procedure. AIMS:This registry aimed to assess the incidence of long-term structural valve deterioration (SVD) beyond 5 years post-TAVI. METHODS:Consecutive living patients who underwent TAVI up until 2014 using any commercially available transcatheter heart valve (THV) at 22 participant centres were enrolled in the European Valve Durability TAVI Registry. All patients underwent comprehensive echocardiographic assessments (61% were evaluated independently by a central core laboratory) within 6 months of enrolment and at least 5 years post-TAVI; SVD was defined according to Valve Academic Research Consortium 3 definitions. RESULTS:A total of 597 patients (aged 79.6±7.1 years at the time of TAVI; 47.2% male, mean Society of Thoracic Surgeons score 5.0%) were included. At a median of 6.1 years of follow-up (interquartile range 5.2-7.3 years), the crude incidence of moderate/severe SVD was 9.5% (n=57; moderate: 6.2%, n=37; severe: 3.4%, n=20). Predictors of SVD identified by Cox regression analysis were use of an intra-annular THV (hazard ratio [HR] 38.44, 95% confidence interval [CI]: 10.8-136.3; p<0.001), a small THV size (HR 4.82, 95% CI: 2.42-9.60; p<0.001) and moderate/severe postprocedural paravalvular leak (HR 3.64, 95% CI: 1.59-8.32; p=0.002). CONCLUSIONS:The incidence of moderate/severe SVD during long-term follow-up after TAVI is low, with severe SVD being even rarer than moderate SVD. SVD occurs more frequently in patients treated with older-generation intra-annular valves and in those with small-sized THVs.

Bicuspid aortic valve (BAV) stenosis poses several challenges when transcatheter aortic valve implantation (TAVI) is performed, including the risk of high residual gradients (HRG). To identify incidence, predictors and outcomes of HRG after TAVI in Sievers type 1 BAV stenosis. Consecutive patients with Sievers type 1 BAV stenosis undergoing TAVI at 24 international centers from 2016 to 2023 were enrolled. HRG were defined as a mean transvalvular gradient ≥ 20 mmHg at 30 days, according to Valve Academic Research Consortium-3 (VARC-3) criteria. The primary endpoint was major adverse cardiovascular events (MACE), defined as a composite of all-cause death, neurologic events or hospitalization for heart failure, assessed at 3 years after TAVI. Secondary endpoints included the single components of the primary outcome. Endpoints were assessed according to the presence of HRG, before and after covariate adjustment for clinically relevant confounders. A total of 972 patients were enrolled. HRG post-TAVI were found in 35 patients (3.6