65 years old male with recurrent pulmonary oedema and evidence of surgical bioprosthesis (Perimount Magna n.25, 2008) degeneration consisting of severe stenosis (grad 84/58 mmHg) and severe paravalvular and intraprosthetic regurgitation.

TEE showing severe intraprosthetic and paravalvular regurgitation as evidence of complex valve degeneration.

Two step procedure:
Paravalvular closure followed by valve-in-valve TAVI

After creating an artero-venous loop between a transeptal and an arterial system, two vascular plugs (AVP III 10×5 and AVP III 8×4 ) were positioned and released, with their final position checked at TEE.

After one month, valve-in-valve TAVI using a Lotus 23 mm valve was performed. The use of a fully repositionable device was helpful to check final gradients before final valve release and obtain the best final position.

Final result showing the absence of any intra-prosthetic or paravalvular regurgitation. Final gradient was 15 mmHg. The patient recently completed 2-year follow-up: he is still asymptomatic with persistently good result at transthoracic echo.