Emergent TAV-in-TAV for Failed Bioprosthetic Valve With Severe Aortic Regurgitation Presenting as a Myocardial Infarction

Background: We present an 82-year-old man with a history of coronary artery disease status after coronary artery bypass grafting, percutaneous coronary intervention, hypertension, and severe aortic stenosis status post transcatheter aortic valve replacement who presented to the emergency department with substernal chest pain and dyspnea. Case Summary: The patient's workup revealed ST-segment elevations in V₁ and chest x-ray suggestive of pulmonary edema. He became hypotensive and was started on pressor support. Left heart catheterization showed a stable coronary artery anatomy but severe aortic regurgitation through a failing Evolut valve (Medtronic). Because of hemodynamic instability, we proceeded with an emergent transcatheter aortic valve-in-valve procedure with a new valve, which resolved his aortic regurgitation. Discussion: Transcatheter aortic valve replacement is typically performed to treat aortic stenosis or regurgitation in stable patients, but in this case it was used to mitigate a patient's severe aortic regurgitation through a prior bioprosthetic valve because of his hemodynamic instability. Take-Home Message: This case highlights the use of an emergent transcatheter aortic valve-in-valve bioprosthetic valve replacement to treat a patient with cardiogenic shock secondary to severe aortic insufficiency.