Successful Valve-in-Valve-in-Valve Procedure in a Patient With Severe Aortic Prosthesis Dysfunction: A Case Report.

Transcatheter aortic valve implantation (TAVI) has become an established treatment for patients with severe aortic stenosis, particularly those with elevated surgical risk. As indications for TAVI expand and patient survival improves, an increasing number of individuals may outlive their initial transcatheter heart valve (THV), creating new challenges in long-term valve management. Repeat procedures such as valve-in-valve implantation are therefore becoming more common. However, repeated transcatheter valve implantation increases the risk of complications, including patient-prosthesis mismatch (PPM), impaired coronary access, and residual or recurrent aortic regurgitation (AR). We report a rare case of early failure of two balloon-expandable transcatheter valves resulting in severe transvalvular regurgitation and recurrent heart failure. The patient was successfully treated with implantation of a third prosthesis using a self-expanding supra-annular valve in a valve-in-valve-in-valve (ViViV) configuration. This strategy corrected the regurgitation while preserving an adequate effective orifice area. This case highlights the importance of individualized valve selection and demonstrates that switching valve platforms from balloon-expandable to self-expanding devices may provide an effective solution in complex redo TAVI procedures.