TAV-in-TAV-in-TAV after treated endocarditis: procedural strategy, imaging planning and 1-year outcome

Given the diverse technical challenges associated with transcatheter valve-in-transcatheter valve procedures, the treatment strategy for each clinical case must be tailored to the individual patient.We present the case of a man in his late 70s with a complex clinical history, including two prior transcatheter aortic valve implantation (TAVI) procedures and infective endocarditis, who later developed severe degeneration of the aortic prosthesis requiring a third transcatheter intervention.Initially treated with a Lotus valve in 2014, the patient underwent a TAV-in-TAV with an Evolut prosthesis in 2022, followed by endocarditis-related degeneration and severe restenosis. In 2024, a third prosthetic valve (Acurate neo2) was implanted using the TAV-in-TAV-in-TAV technique.With expanding indications for TAVI and increasing longevity among treated patients, complex multi-prosthesis interventions may become more frequent, highlighting the need for improved procedural planning, imaging strategies and long-term surveillance. At 1-year follow-up, the patient remains asymptomatic with preserved valve function.This case illustrates the feasibility of a third TAVI after treated prosthetic valve endocarditis, supported by CT-guided procedural planning and 1-year follow-up, which remains scarcely reported in the literature.