Emergency Valve-in-Valve Transcatheter Aortic Valve Implantation in a Patient With a Degenerated Surgical Xenograft and High Body Mass Index Presenting With Recurrent Pulseless Electrical Activity Arrest

Degeneration of bioprosthetic aortic valves is a recognised late complication that may present with severe stenosis, regurgitation, or acute haemodynamic compromise. Redo surgical aortic valve replacement in patients with obesity and multiple comorbidities carries substantial perioperative risk, making valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) an important alternative. We report a middle-aged man with obesity and a prior bovine xenograft aortic valve replacement who presented with progressive heart failure, severe prosthetic aortic stenosis, and recurrent pulseless electrical activity arrest. He was stabilised with vasopressor support and emergency balloon aortic valvuloplasty before undergoing successful left transfemoral ViV-TAVI with coronary protection and common femoral artery repair. His postoperative course was complicated by delayed vascular infection and bleeding, requiring further surgical and endovascular intervention. This case highlights the role of urgent ViV-TAVI in critically unwell patients, the technical challenges of reintervention in obesity, and the importance of multidisciplinary management in complex structural heart disease.