(Figure F).
Two weeks later, the patient underwent valve-in-valve (VIV) transcatheter aortic valve replacement (TAVR) utilizing a 23 mm Edwards Sapien Ultra valve under transesophgeal echocardiographic (TEE) guidance. The valve was deployed somewhat more ventricular than is typical in order to utilize the valve’s sealing skirt to seal the large area of PVL involving the superior LVOT. Following valve deployment, additional balloon post-dilatation was performed using a 22mm Tru Dilatation Balloon (Bard) to deliberately fracture and enlarge the bioprosthetic surgical valve to further seal the large area of PVL and to assure optimal transvalvular hemodynamics (Figure G). The pressure gradient across the aortic valve resolved after TAVR implantation (Figure H). Final TEE imaging revealed near total resolution of both PVL and aortic stenosis (Figure I).