Abstract
BACKGROUND: Surgical reintervention for degenerated aortic homografts is associated with high operative risk. Transcatheter aortic valve replacement (TAVR) offers a less invasive alternative but is technically challenging with current-generation devices. CASE SUMMARY: A 72-year-old man with history of aortic homograft replacement presented with acute dyspnea due to severe aortic regurgitation (AR). Valve-in-valve TAVR was performed (29-mm Evolut FX+), with mild paravalvular AR. Subsequent transesophageal echocardiography revealed supra-annular valve position with a prolapsing, uncovered homograft leaflet, causing recurrent severe AR. Bailout redo-TAVR was performed (26-mm Sapien S3 Ultra) with intentional deployment at a deeper position, leading to successful AR resolution. DISCUSSION: This case demonstrates the technical difficulties with TAVR in failed aortic homografts, especially when the failure mechanism is AR. Owing to lack of leaflet calcification and difficulty with visualization, TAVR using commercial devices is associated with risk of valve malposition and need for a second valve. TAKE-HOME MESSAGE: Dedicated TAVR devices for AR will likely become the preferred treatment for failed homografts after commercial approval.