N.A.

75 years old lady with came to our emergency department with recurring breathlessness. She had prior Aortic Valve Stenosis and Ischemic Heart Disease. Coronary wise revealed that she had Single Vessel Disease, with PCI to LAD done previously. History revealed she had undergone surgical Aortic Valve Replacement with a suture-less, bioprosthetic 'Perceval' valve in 2012. Clinically she exhibits symptoms and signs of mild congestive heart failure, in which workup was done to elicits the true causes.

Transthoracic echo revealed the following parameters regarding the aortic valve.- AV mean PG 51 mmHg- Max PG 75 mmHg- EOA(VTI) 0.8c m²- V Peak velocity: 4.3 m/s,- Acceleration time: 128 msec, DVI: 0.27.- Mild moderate transvalvular leakage- AR (P1/2t) 456 msec- Vena contracta 0.3 cm- Desc ao holodiastolic reversal VTI 12.7 cmIn summary, it shows evidence of earlier than expected structural valve degeneration.
Her biplane LVEF was 51%. There was hypokinesia in the anterior and anterolateral wall.
Echo 1.avi

Echo 3.avi

Coronary Angiogram revealed 3-vessel disease with ISR of mid LAD of 95%, There is also de novo, severe lesions in the mid LCx and mid RCA.
All of these were treated.- LAD stented with Synergy 3.0 x 38 mm DES- LCx treated with drug coated balloon Sequent Please Neo 2.75 x 20 mm - RCA stented with Biomatrix Alpha 3.0 x 33 mm
Once her coronaries were sorted out, we planned for an elective TAVI with a newer balloon expandable valve Myval by Meril. Her BSA was only 1.47. Height 147 cm, weight 52 kg.
1st PCI 13.avi
1st PCI 9.avi
2nd PCI 5.avi

TAVI procedure was done under general anaesthesia. A temporary pacing wire was inserted via the right internal jugular vein. Two 6 Fr arterial access obtain from right femoral artery - for pigtail catheter and JL 4.0 to protect left coronary artery. Left femoral artery was obtained, then inserted later with 14 Fr Python sheath. The sheath expands momentarily, to allow passage of Myval crimped balloon catheter up to size 29 mm. Here we selected Myval size 23 mm. After successful crossing of the valve, wire was exchanged with Safari wire. 
There was some resistance in inserting the crimped valve via the 14 Fr sheath. However, this resistance was overcame later. TAVI-in-valve was deployed with rapid pacing as per usual manner. 
Post procedure, she developed occasional complete heart block (in background bifascicular block). She later underwent Cardiac Resynchronization Therapy Defibrillator device successfully. Follow up Transthoracic Echo only showed minimal paravalvular prosthetic leak at 12'o clock position. Otherwise, the valve is functioning well.
TAVI 3.avi
TAVI 5.avi
TAVI 6.avi

The case depicts importance of maintaining aortic valve effective orifice area. The first attempt was by surgical method, in which a suture-less bioprosthetic valve was utilized. However, it suffered structural valve degeneration. Utilizing MyVal, we were able to put a reasonable size 23 mm balloon expandable valve for valve-in-valve. The utility of a smaller, 14 Fr insertion sheath was useful as well in prevention of vascular trauma in this small size lady.