To help address the growing challenge of structural valve deterioration following TAVR, the international, multidisciplinary Heart and Valve Collaboratory has released consensus-based procedural workflows for re-do TAVR. The two-part document, presented at NY Valves 2026 and published simultaneously in JACC: Cardiovascular Interventions, provides tailored guidance for both short-frame and tall-frame valves.

A CT-based workflow is outlined and emphasized in both documents, integrating standardized planning concepts, in-vivo sizing and procedural execution to improve safety and reproducibility. Both cover major procedural techniques and components, including pre- and postdilatation strategies, valve-sizing nuances, frame alignment and deployment. While these recommendations standardize best practices, they remain consensus-based and require further validation.

In part one, Andrei Pop, MD, FACC; Gilbert H.L. Tang, MD, MSc, MBA, FACC, et al., address the challenges of implanting short-frame balloon-expandable valves within failed short- or tall-frame transcatheter valves, that is, "short-in-short" and "short-in-tall" procedures, the most common TAV-in-TAV combinations, which they describe as a geometry problem.

Optimal valve sizing and positioning, mitigation of coronary obstruction, sinus sequestration and preservation of future coronary and reintervention options are among the challenges reviewed across nine sections, each with its own key practical takeaways.

Overall key highlights include: configuration-specific planning is needed for short-in-short and short-in-tall redo-TAVR; implant depth determines neoskirt plane (NSP), leaflet overhang, coronary access and mitigation risk; in-vivo CT sizing should be integrated with index TAV failure mechanism, coronary risk and TAV #2 migration risk assessment; predilatation and postdilatation should be goal-driven and CT-guided; and current recommendation require prospective evaluation.

"[TAV failure] recognition, selection between TAV-in-TAV versus surgical explant or alternative strategies and longitudinal follow-up are best guided by a structured, anatomy-driven workflow that integrates valve design, coronary risk assessment and multimodality imaging," the authors write.

In part two, Vinayak N. Bapat, MBBS; Gilbert H.L. Tang, MD, MSc, MBA, FACC, et al., address tall-fame self-expanding valves implanted within failed short- or tall-fame valves, known as "tall-in-short" and "tall-in-tall" scenarios.

Among the challenges in this setting are anchoring, constrained expansion, valve alignment and the risk of obstruction or sinus sequestration driven by the resulting NSP. These and more are reviewed across 12 sections with key practical takeaways with each.

Overall highlights in this document include the need for CT-guided, configuration planning; tall TAV#2 creates a high NSP, making coronary risk and future access central to planning; in-vivo CT sizing for TAV#2 should integrate index TAV expansion, failure mechanism; landing-zone geometry and coronary risk; deployment should prioritize coaxiality, inflow-target accuracy and commissural/cell alignment when feasible; and coronary preservation strategies should be planned upfront in high-risk anatomies.

"For high-risk [tall-frame] anatomies, this workflow may help identify cases in which referral to experienced structural heart centers is appropriate, given the steep learning curve and need for advanced imaging, coronary protection, leaflet modification, and surgical or hybrid bailout capabilities," Bapat, et al., write. "As experience grows, these algorithms require systematic validation and refinement through benchtop testing, multicenter registries, and prospective studies across the full spectrum of redo-TAVR practice."

Transcatheter Leaflet Modification During TAVR Feasible, Effective in Asian-Pacific Population

In the first systematic study of transcatheter electrosurgical leaflet modification among high-risk patients undergoing TAVR and living in the Asia-Pacific region, the BASILICA, UNICORN and BASILICA-UNICORN techniques were feasible and associated with acceptable short-term outcomes, according to research presented at the NY Valves 2026 and simultaneously published in JACC: Asia.

Led by the Asia-Pacific Electrosurgery Working Group, the retrospective observational registry included 100 consecutive patients at seven experienced centers across the region, between April 2019 and January 2026. A high proportion of patients was women (72%), and the median age was 80 years.

Most index valves were small (≤21 mm), and the BASILICA technique was used in 67% of patients, UNICORN in 30% and BASILICA-UNICORN in 3%.

Results showed that procedural success – defined as successful leaflet traversal, leaflet modification and transcatheter heart valve implantation without coronary obstruction, emergent surgery, stroke or mortality at 30 days – was achieved in 85% of BASILICA cases and 97% of UNICORN cases. Coronary obstruction occurred in 3% of patients who underwent the BASILICA technique.

Notably, investigators Chun-Ka Wong, MBBS, et al., observed that the annual case volume increased 10-fold over the study period – reflecting the anticipated increase in the need for these approaches as TAVR indications expand to younger, lower risk patients.

The authors highlight these results fill an important geographic gap in evidence and in a patient population with "distinct anatomic features, including small aortic root, and in certain ethnic groups, a higher proportion of bicuspid aortic valves."

In an accompanying editorial comment, Yuxin He, MD, and JACC: Asia Editor-in-Chief Jian'an Wang, MD, PhD, FACC, call the study a "compelling illustration of regional anatomical adaptation," that demonstrates "not only that BASILICA and UNICORN are feasible in this setting, but that local operators have adapted and refined these techniques to overcome anatomical constraints."