The matryoshka procedure

We present the case of a 73‐year‐old male patient undergoing a modified Bentall–DeBono procedure in 2015 due to aortic stenosis and aortic aneurism involving the root. A bioprosthetic stented conduit made with a stented Edwards Perimount 21‐mm bioprosthesis and a Vascutek Valsalva 28‐mm Dacron graft was implanted along with a mitral annuloplasty. Five years later, due to early degeneration of the bioprosthesis and a progression of the mitral disease, he underwent a second surgical procedure where a Medtronic Mosaic 27‐mm valve prosthesis was implanted in mitral position and a sutureless Livanova Perceval 23‐mm valve in aortic position. Because of the difficulty in removing the previously implanted aortic prosthesis, the Perceval valve was inserted inside the frame of the PeriMount as an open “valve‐in‐valve” procedure. In October 2020, the patient underwent a ViV TAVI with a 23‐mm Edwards Sapien 3 (Edwards Lifescience). After induction of general anesthesia and heparin administration, the procedure was performed via right femoral artery approach with preimplantation of two Proglides. After transfemoral insertion of a 14‐French sheath, the aortic valve was crossed with a 0.035‐in. straight guide‐wire, taking care to avoid crossing the crowns of Perceval frame. After exchange of the standard wire with an extra‐stiff 0.035‐in. Safari wire, the Sapien‐3 valve was advanced across the two previously implanted surgical valves and deployed at the level of the Perceval ring. After bioprosthesis deployment, peak‐to‐peak left ventricular aortic gradient was reduced from 51 to 16 mmHg.