Off-Label TAVR: The Valve-in-Valve Solution

By Marat Fudim, MD

Transcatheter aortic valve replacement (TAVR) is an established alternative to surgical aortic valve replacement (SAVR) for the treatment of severe aortic stenosis in patients at high surgical risk, and is considered superior to medical management in patients who are deemed inoperable.  Since the introduction of TAVR, several reports have suggested that off-label use of TAVR for failed surgically inserted bioprosthetic valves (valve-in-valve) is feasible and effective.  However, to our knowledge there have not been any reports of valve-in-valve TAVR for hemodynamically unstable patients due to acute bioprosthetic valve failure.  

Acutely failing bioprosthetic valves represent a clinical emergency and are exceedingly challenging given the paucity of therapeutic options.  Oftentimes, these patients are not reoperative candidates due to clinical instability.  In this months’s Journal of Invasive Cardiology, we present two cases of acute aortic bioprosthetic valve failure with cardiogenic shock treated with TAVR.  These cases were characterized by hemodynamic instability with vasopressor dependence and (multiple) organ failure.  Our two cases demonstrate that TAVR should be considered as a treatment option for unstable patients with bioprosthetic failure.

This month’s issue also features a thought-provoking commentary on the aforementioned paper:

A selection of “Valve-in-Valve” articles available at


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