The work by Dr. Julien Adjedj1 and his team from Arnault Tzanck Institute in France published in this edition of our journal marks not one but two milestones. Not only does it contribute innovative clinical experience regarding the valve-in-valve approach in degenerated transcatheter valves, but it also signals the beginning of highly valued international scientific collaboration.

The article describes three clinical cases successfully managed through the implantation of self-expanding valves with intra-annular leaflets in previously implanted balloon-expandable bioprostheses. This technical approach stands out for its anatomical and hemodynamic rationale. It preserves coronary access, prevents valve obstruction, and maintains low gradients—critical factors to ensure not only immediate success but also viability for future reinterventions.

The use of self-expanding intra-annular valves in these cases is a long-term strategy, particularly relevant given the growing population of “younger” patients undergoing transcatheter aortic valve implantation (TAVI) as first-line therapy. Taking into account the possibility of a planned “third TAVI” procedure, this approach becomes a key element in the design of stepwise therapies for aortic valve disease.

From an editorial perspective, this publication reinforces one of the core goals of our journal: to be a channel for science communication for our Spanish-speaking community and beyond, becoming a meeting point for colleagues from all over the world who, as in this case, share advancements with direct applicability in our daily practice. We appreciate the trust of Dr. Julien Adjedj and his team have vested in us by choosing our journal as the platform to share their clinical experiences.

Regarding the topic in general, the global expansion of TAVI in younger patients with lower surgical risk confronts us with a new clinical scenario: the treatment of implanted transcatheter valve dysfunction. This challenge, once rare, will become increasingly common as both prosthesis and patient longevity rise.

The incidence of significant structural dysfunction after TAVI remains low in the midterm, with reports ranging from 1–3% at 5–8 years of follow-up2, 3. The main causes behind this phenomenon include structural leaflet degeneration, thrombosis, pannus, endocarditis, malapposition, and prosthesis-patient mismatch. This issue, which has been well documented in relation to surgical bioprostheses, is also becoming a reality in relation to transcatheter valves, particularly self-expanding prostheses implanted in younger patients.

Patients typically present with progressive dyspnea or congestive heart failure, although in some cases, the dysfunction is detected incidentally during echocardiographic follow-up. Doppler findings depend on the failure mechanism: stenosis (high gradients and reduced area) or significant regurgitation (intra- or paravalvular jet). Multislice computed tomography (CT) is essential to assess thrombi, pannus, or risk of coronary obstruction4.

The therapeutic approach poses technical dilemmas. The choice between a balloon-expandable or self-expanding prosthesis (each with its advantages and disadvantages) must consider the original prosthesis type, annulus diameter, relation to the coronary arteries, and risk of coronary obstruction. In general, balloon-expandable valves are preferred in well-defined annuli with wide coronary sinuses, while self-expanding valves may offer advantages in large annuli or upon risk of underexpansion5, 6. Pre-procedural CT assessment and, in some cases, planning for coronary protection techniques are essential.

The future of TAVI-in-TAVI will be shaped by technological innovation (lower-profile prostheses), the growing use of 3D computational planning (already under active development in our field), and the need for long-term studies evaluating durability and clinical outcomes of this strategy. Interventional cardiology thus faces a new therapeutic paradigm that will demand personalized strategies and more robust evidence.

Dr. PhD Carlos Fernández Pereira FACC, FESC, FSCAI
Editor-in-Chief, Argentinian Journal of Interventional Cardiology (RACI)
cfernandezpereira@centroceci.com.ar

1. Mark N, Léo C, Pierre M et al. Valve-in-Valve utilizando una válvula autoexpandible con valvas intraanulares en válvulas balón-expandibles.revista Argentina de Cardioangiologia Intervencionista.2025.

2. Yoon S-H, Barbanti M, Allgar V, et al. Outcomes in patients with degeneration of transcatheter aortic bioprostheses: A multicenter study. J Am Coll Cardiol. 2017;70(5):605-614.

3. Landes U, Webb JG, De Backer O, et al. Repeat transcatheter aortic valve replacement for transcatheter prosthesis dysfunction. J Am Coll Cardiol. 2020;75(17):1882-1893.

4. Tzimas G, Meier D, Beneki E, et al. Current Trends and Future Challenges in Transcatheter Aortic Valve Replacement: Utility of Cardiac Computed Tomography Angiography. Journal of Clinical Medicine. 2025; 14(7):2474.

5. Ribeiro HB, Webb JG, Makkar RR, et al. Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation. J Am Coll Cardiol. 2013;62(17):1552-1562.

6. Meier D, Fournier S, Sathananthan J. Redo TAVR: Technical Considerations Key concepts and risk management for procedural planning of redo TAVR. Cardiac Interventions Today. March/April 2023 Vol. 17, No. 2.

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