Valve-In-Valve TAVI in a Patient With Dextrocardia, Situs Inversus, and Challenging Commissural Alignment

Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) for dextrocardia is challenging. An 81-year-old man with dextrocardia and situs inversus developed prosthetic aortic stenosis. Loading Evolut FX+ C-tab 180° upside down in a delivery catheter facilitates commissural alignment during ViV-TAVI in dextrocardia. To accommodate anatomical variations, the flush-port position can be adjusted. In this case, the flush port was positioned 5-o'clock (60° from the usual 3-o'clock position) to align the TAVI valve with former prosthesis, as the former prosthetic valve commissure was oriented 60° from native commissures to preserve coronary access for abnormal left coronary artery originating from native commissures. This case illustrates strategies for commissural alignment during ViV-TAVI in dextrocardia.