Background: Valve-in-Valve (VIV) transcatheter aortic valve replacement (TAVR) is a potential solution for malfunctioning surgical aortic valve prostheses, though limited data exist for its use in Perceval valves. Methods: searches were performed on PubMed and Scopus up to 31 July 2023, focusing on case reports and series addressing VIV replacement for degenerated Perceval bioprostheses. Results: Our analysis included 57 patients from 27 case reports and 6 case series. Most patients (68.4%) were women, with a mean age of 76 ± 4.4 years and a mean STS score of 6.1 ± 4.3%. Follow-up averaged 9.8 ± 8.9 months, the mean gradient reduction was 15 ± 5.9 mmHg at discharge and 13 ± 4.2 mmHg at follow-up. Complications occurred in 15.7% of patients, including atrioventricular block III in four patients (7%), major bleeding or vascular complications in two patients (3.5%), an annular rupture in two patients (3.5%), and mortality in two patients (3.5%). No coronary obstruction was reported. Balloon-expanding valves were used in 61.4% of patients, predominantly the Sapien model. In the self-expanding group (38.6%), no valve migration occurred, with a permanent pacemaker implantation rate of 9%, compared to 5.7% for balloon-expanding valves. Conclusions: VIV-TAVR using both balloon-expanding and self-expanding technologies is feasible after the implantation of Perceval valves; however, it should be performed by experienced operators with experience both in TAVR and VIV procedures.

The durability of transcatheter mitral valve replacement (TMVR) using the Edwards Sapien valve in a mitral ring remains uncertain. This report details a complex transseptal valve-in-valve-in-ring procedure and discusses long-term outcomes. A 73-year-old man, with a history of coronary bypass surgery and mitral valve reconstruction, underwent valve-in-ring implantation with an Edwards Sapien 3 26-mm prosthesis 7 years ago. Now he presented with progressive dyspnea (NYHA functional class III) due to severe prosthetic valve degeneration. A transseptal valve-in-valve intervention was performed using an Edwards Sapien 3 Ultra Resilia 26-mm valve inside the degenerated Sapien 3 26-mm valve within a 30-mm Physio ring. Procedural challenges of valve-in-valve-in-ring interventions and their impact on TMVR longevity are reviewed, highlighting imaging guidance, transseptal puncture, and valve durability as key factors for long-term outcomes. Transseptal valve-in-valve-in-ring implantation provides an alternative strategy for structural mitral valve deterioration. Long-term durability of TMVR requires continued assessment through dedicated registries and follow-up studies.