Valve-in-valve transcatheter aortic valve replacement: the challenge of the next future

In recent years, an increasing number of bioprostheses have been implanted, and in the near future more and more patients will be candidates for reoperation due to structural deterioration of the valve. Valve-in-valve transcatheter aortic valve replacement (ViV TAVR) has become a safe and effective alternative to surgery and is currently approved for higher-risk, inoperable patients. From the most recent studies, early mortality has decreased and improvements in symptoms and quality of life of treated patients have been documented. ViV TAVR is a complex procedure that can present many pitfalls and therefore must be performed in high volume centers and with experienced staff because the risk of peri- and post-procedural complications is much higher than TAVR on native valve. In this review, we analyze the main procedural issues reported in the literature during ViV TAVR procedures: elevated postprocedural gradients, coronary obstruction and thrombosis of the leaflets of the bioprosthesis. Because of the opening of TAVR to younger and younger patients, thus with a longer life expectancy than the durability of the bioprosthesis, the next challenge will be the management of the lifetime strategy of patients with aortic stenosis, as the first type of intervention will influence all future therapeutic choices of our patient.