We present a 47-year-old man with end-stage renal failure on haemodialysis. Four years prior, he underwent coronary artery bypass grafting with the left internal mammary artery to the left anterior descending artery with bioprosthetic surgical aortic valve (SAV) replacement [23 mm Carpentier-Edwards Magna Ease (ME)] for ischaemic heart disease and severe aortic regurgitation from a prolapsed non-coronary cusp (Panel A). The patient was non-compliant to medications. Two years later, he presented with heart failure from severe degenerated (non-thrombotic) prosthetic aortic valve stenosis with a mean transaortic gradient of 64 mmHg (Panel B: Pedoff probe measurement). This valve failure was attributed to hyperparathyroidism. He declined a re-do SAV replacement. During induction for transcatheter aortic valve (TAV) replacement, the patient developed cardiac arrest necessitating emergency extracorporeal membrane oxygenation support and implantation of a 23 mm Edwards Sapien 3 valve (S3) with residual mild paravalvular aortic regurgitation (Panel C), mean aortic gradient of 23 mmHg, and effective orifice area of 0.97 cm². He defaulted follow-up. The patient with dyspnoea 2 years later with severe stenosis of the S3 valve with leaflet calcification and a left ventricular ejection fraction of 15%. Computed tomography (CT) showed concomitant hypoattenuated leaflet thickening (Panel D, black arrow) but a trial of anticoagulation was unsuccessful. The heart team deemed him inoperable hence a TAV-in-TAV procedure was performed. To avoid potential patient–prosthesis mismatch (PPM), balloon valvuloplasty was performed in an attempt to fracture the Magna Ease sewing ring (through the initial S3 valve) with an oversized 24 mm True dilatation balloon to 12 atm, this stretched the Magna Ease sewing ring and expanded the initial S3 but could not fracture the sewing ring. This was followed by the insertion of a Medtronic Evolut R 26 mm supra-annular prosthesis (ER) (Panel E). Post-TAV-in-TAV gradient was low with no PPM. A computed tomographic scan demonstrated the TAV-in-TAV-in-SAV (Panel F, 3D CT reconstruction—blue: ME SAV; orange: S3 TAV; and grey: ER TAV). He was then scheduled for parathyroidectomy.

中文翻译：

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一名患有终末期肾功能衰竭和甲状旁腺功能亢进症的人，在手术生物人工主动脉瓣中重复经导管主动脉瓣置换，同时避免了患者与假体的不匹配。

我们介绍了一名47岁的男性，因血液透析终末期肾功能衰竭。四年前，他接受了冠状动脉搭桥术，将左乳内动脉移植到左前降支动脉，并用生物假体手术主动脉瓣（SAV）替换[23 mm Carpentier-Edwards Magna Ease（ME）]治疗缺血性心脏病和重度主动脉脱垂的非冠状动脉瓣关闭不全（图A）。该患者不服药。两年后，他因严重的变性（非血栓性）人工主动脉瓣狭窄而出现心力衰竭，平均经主动脉梯度为64 mmHg（图B：Pedoff探针测量）。该瓣膜衰竭归因于甲状旁腺功能亢进。他拒绝重做SAV替代品。在经导管主动脉瓣置换术（TAV）的诱导过程中，^2个。他拖欠了后续行动。2年后患有呼吸困难的患者，S3瓣膜严重狭窄，小叶钙化，左心室射血分数为15％。计算机断层扫描（CT）显示伴随的小叶增厚减薄（图D，黑色箭头），但抗凝试验未成功。心脏小组认为他无法手术，因此进行了TAV-TAV手术。为避免潜在的患者与假体不匹配（PPM），进行了球囊瓣膜成形术，试图用超大的24 mm True扩张球囊将Magna Ease缝合环（通过最初的S3瓣膜）破裂至12 atm，这使Magna Ease缝合得以延长环并扩展了初始S3，但无法使缝纫环断裂。随后插入Medtronic Evolut R 26 mm瓣环上假体（ER）（面板E）。TAV后TAV中的梯度很低，没有PPM。计算机断层扫描显示TAV-TAV-SAV（面板F，3D CT重建-蓝色：ME SAV；橙色：S3 TAV；灰色：ER TAV）。然后，他被安排进行甲状旁腺切除术。