Intraoperative TEE Detection of Guidewire Malposition and Incomplete Valve Expansion in Valve-in-Valve TAVI for Trifecta Bioprosthesis Failure: a Case Report

Structured Abstract Background Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) is widely used for failed surgical bioprostheses; however, procedural pitfalls remain, particularly in valves prone to early structural deterioration. Case summary An 84-year-old woman with a failed 21-mm Trifecta bioprosthesis underwent ViV-TAVI. Although the guidewire crossed smoothly and fluoroscopy appeared reassuring, incomplete valve expansion occurred. Intraoperative transoesophageal echocardiography revealed that the guidewire had passed between degenerated leaflets rather than through the true central orifice. After repositioning under TEE guidance, full symmetric valve expansion and optimal haemodynamics were achieved. Discussion This case highlights the risk of false procedural reassurance during ViV-TAVI and underscores the importance of actively confirming central guidewire trajectory, particularly in failed Trifecta bioprostheses.