Four-Step Framework for Valve-in-Valve Transcatheter Aortic Valve Replacement for Failed Surgical and Transcatheter Aortic Bioprostheses.

Transcatheter aortic valve replacement (TAVR), originally developed to treat native aortic valve disease, has become increasingly adopted in the valve-in-valve (ViV) setting to manage bioprosthetic valve dysfunction of both surgically implanted bioprostheses (TAV-in-SAV) and prior transcatheter valves (TAV-in-TAV). Recent advances have significantly refined the ViV technique to address procedural challenges, including suboptimal hemodynamic outcomes and the risk of coronary obstruction. This review summarizes the current clinical data supporting the use of TAVR in a ViV setting and outlines a structured, four-step framework that encompasses procedural planning, including determining the perioperative risk for a patient, identifying the mode of valve failure, recognizing valve-specific implantation strategies, and assessing concomitant structural lesions. This review also aims to synthesize current evidence into a clinically actionable format, helping to guide heart team discussions, pre-procedural planning, and patient counseling.