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Valve-in-valve (VinV) transcatheter aortic valve replacement (TAVR) has become a well-established therapy for patients with failed surgical bioprosthetic valves (BPV) who are at high risk for reoperation1. In the largest series to date, VinV TAVR demonstrated a one-year survival rate of 83.2%, which was similar to that of patients undergoing native aortic stenosis (AS) TAVR in high-risk populations2,3. Of note, in that series, most patients (53.4%) were treated with a second-generation balloon-expandable transcatheter heart valve (THV), namely the SAPIEN XT THV (Edwards Lifesciences, Irvine, CA, USA). Over the decade since its introduction for the treatment of native AS, iterative modifications to THV design and functionality as well as advances in imaging and procedural technique have led to a dramatic improvement in both safety and patient outcomes over the original procedures4. In particular, the secondgeneration SAPIEN XT valve has now been largely replaced by the SAPIEN 3 valve (Edwards Lifesciences), which has several new features specifically designed for use in native AS TAVR. These include a fabric cuff to reduce paravalvular leak (PVL), a longer stent frame to simplify deployment positioning within the native aortic annulus, and a smaller crimped profile (18-21 Fr outer diameter) that allows introduction into smaller (14-16 Fr) expandable sheaths. The performance of the SAPIEN 3 in native AS has been promising4. What is not known to date, however, is whether the SAPIEN 3 THV would perform as well as or better than the SAPIEN XT in VinV TAVR. In this issue of EuroIntervention, Seiffert and colleagues have used an expanded data set from the VIVID registry to answer that very question5.

Valve-in-valve TAVR using the SAPIEN 3 transcatheter heart valve: still plagued by patient-prosthesis mismatch