TAV-in-TAV With Coronary Protection After Premature Valve Failure: The Second Time Is Not the Charm.

BACKGROUND: Redo transcatheter aortic valve replacement (TAVR; TAV-in-TAV procedure) is technically challenging. We report a case of TAV-in-TAV requiring right coronary artery (RCA) protection. CASE SUMMARY: An 81-year-old man underwent TAVR with a self-expanding valve in 2021 and presented in 2025 with heart failure symptoms. Multimodality imaging demonstrated severe aortic regurgitation from premature structural valve degeneration. A short-in-tall TAV-in-TAV strategy was planned. Bulky leaflet calcification near the RCA ostium prompted coronary protection. After difficult RCA engagement requiring multiple access changes, the valve was deployed using the engaged guiding catheter as a fluoroscopic landmark. Coronary flow was preserved without bailout stenting. No residual regurgitation was observed on postprocedural imaging. DISCUSSION: We highlight the importance of preprocedural planning in redo TAVR and illustrate real-world challenges in coronary access despite meticulous planning. TAKE-HOME MESSAGES: Preprocedural planning and access flexibility are essential in redo TAVR. Lifetime coronary access should be considered during index valve selection.