Transcatheter Aortic Valve-in-Valve Implantation for Failing Stentless Bioprosthetic Aortic Valves: An International Multicentre Retrospective Analysis

Background: Valve-in-valve aortic valve implantation (ViV-TAVI) offers a less invasive treatment option for patients with a failing surgical bioprosthesis, avoiding the need for redo surgery. ViV-TAVI within a stentless bioprosthetic valve poses unique technical challenges. We report an international, multicentre experience evaluating procedural and clinical outcomes for patients undergoing ViV-TAVI for failed stentless bioprosthetic aortic valves. Aims: To evaluate the procedural feasibility, safety, and clinical outcomes of ViV-TAVI performed for failed stentless bioprosthetic aortic valves in an international, multicentre cohort. Methods: We retrospectively analysed 65 patients who underwent ViV-TAVI for stentless valve failure between 2010 and 2024. Outcome endpoints were based on the Valve Academic Research Consortium 3 (VARC-3) criteria. Results: Sixty-five patients (mean age 78.8 ± 10.2 years; 66.1% male; mean STS-PROM 6.9 ± 4.7) were included. The mean interval between surgical valve implantation and failure was 12.9 ± 4.1 years, with regurgitation the predominant mechanism of valve dysfunction (52.3%). Procedural success was achieved in 92.3%. 17 patients (26.2%) had upfront coronary protection. Despite this, six patients required unplanned percutaneous coronary intervention (PCI) for coronary obstruction. The 30-day and 1-year mortality rate was 0% and 8% respectively. Conclusions: ViV-TAVI was an effective intervention for patients with failing stentless bioprosthetic valves, with high procedural success rates despite unique technical challenges. Careful preprocedural imaging, planning, and implementation of coronary protection strategies are critical for optimal patient outcomes.