Figure 1.

Positioning the CoreValve often proved to be very difficult because of the turbulence due to the pure native aortic regurgitation. The valve may be deployed too deeply into the left ventricle and causes moderate to severe residual paravalvular leakage (PVL). In our series, all of the PVL complicating low deployments of a CoreValve prosthesis were treated by transcatheter insertion (“TAVR-in-TAVR”) of a second transcatheter heart valve. (A) In one of the patients needing CoreValve-in-CoreValve implantation, significant residual PVL was evident, owing to a lack of radial strength of the second 31 mm CoreValve to afford enough stent expansion of the first 31 mm CoreValve. The diameter of the first CoreValve frame at its waist was 24.0 mm (black double arrow), occupying the annulus in this case. Implantation of the second CoreValve increased the diameter at the waist from 24.0 to 25.6 mm (white double arrow), with significant recoil (B). In another patient with low deployment of a 31 mm CoreValve prosthesis, the diameter of the device at the aortic annulus was 27.6 mm (black double arrow) and 24.0 mm at its waist (dashed black double arrow) (C). We implanted a 29 mm Sapien XT valve in the malpositioned CoreValve in order to eliminate the residual PVL. The final diameters both at the annulus (white double arrow) and the waist (dashed white double arrow) were 29.2 mm (D).