Redo Transcatheter Aortic Valve Replacement for Degenerated Valve With High-Risk Coronary Anatomy

Objectives: Here we describe a step-by-step, imaging-guided technical approach to redo transcatheter aortic valve replacement (TAVR) in a degenerated ACURATE Neo2 valve (Boston Scientific) with high-risk right coronary artery (RCA) anatomy and highlight strategies to prevent coronary obstruction during valve-in-valve implantation. Key Procedural Steps: A 76-year-old man who previously underwent TAVR using a 27-mm ACURATE Neo2 valve presented with heart failure due to severe prosthetic aortic regurgitation. Preprocedural computed tomography demonstrated a critically high-risk anatomy for RCA obstruction, with the coronary ostium originating between the upper and lower crowns of the Neo2 frame and limited sinus of Valsalva accommodation. Because of his prohibitive surgical risk, redo TAVR was performed using a 26-mm SAPIEN 3 valve (Edwards Lifesciences). The procedure incorporated meticulous computer tomography–based planning, prophylactic RCA wiring for coronary protection, and stepwise, high and controlled valve deployment with real-time positional adjustments to achieve precise alignment at the Neo2 upper crown. Potential Pitfalls: Valve-specific ACURATE Neo2 geometry increases coronary obstruction risk, making careful imaging, valve selection, and coronary protection essential.