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Annibali et al. Mini-invasive Surg 2022;6:12 https://dx.doi.org/10.20517/2574-1225.2021.101 Page 9 of 16

Figure 2. Stented valves prone to fracture.

endocarditis, those with severe paravalvular leak, other heart or aortic diseases, and at high risk of coronary
[64]
artery occlusion .

Indeed, while TAVR is associated with almost twice the in-hospital mortality compared with SAVR, TAVR-
in-TAVR represents a less invasive therapeutic option, with reduced 30-day mortality and lower incidence
of major adverse cardiac events [68-70] . Unfortunately, this will not be a feasible procedure for all patients;
therefore, one must be aware of the future importance of the first treatment decision in the young patient
with aortic stenosis .
[64]

The need to implant a second (or third) TAVR for acute bioprosthesis failure occurs in 1.4%-6.7% of cases
(most frequently for acute aortic regurgitation), with satisfactory long-term results similar to those with a
single valve [18,53,56] [Figure 3]. In the case of a larger annulus, the likelihood of a second valve is higher .
[71]
Outcomes of TAVR for treatment of failed THVs, albeit in a small series, appear satisfactory . In the
[72]
absence of data regarding the bioprosthesis, pre-procedure CT planning is critical to assess its internal
diameter at the level of leaflets insertion .
[25]

In the case of TAVR SVD, it is possible to insert a valve of similar size to the one placed in the original
procedure. In the case of a BE valve inside a SE valve, we can use the annulus measurements of the original
native valve to select the valve size. A BE valve within a SE valve can effectively treat, via a sealing effect,
moderate-to-severe paravalvular regurgitation by exploiting the increased radial strength of the BE .
[13]