This state-of-the-art article reviews current literature and future directions in transcatheter valve-in-valve (VinV) and valve-in-ring (VinR) implantation. The following are 10 key points to remember:

1. Internal prosthesis size varies between different valves even with the same reported size. Given the importance of accurate sizing for possible transcatheter VinV or VinR implantation, heart teams must review literature or manufacturer specifications to determine precise size. The value of pre-procedural sizing by computed tomography (CT) or transesophageal echocardiography remains unclear.
2. Dysfunction of bioprosthetic valves is most commonly due to cusp calcification, which can result in stenosis from cusp stiffening and regurgitation due to tears. Other mechanisms include collagen deterioration, tissue overgrowth, thrombus, or paravalvular leaks. Deterioration requiring re-intervention is over 50% at 15 years.
3. Several studies have reported results of transcatheter VinV for aortic bioprosthetic dysfunction, with studies ongoing. Most published data have used the Edwards or CoreValve systems. A smaller number of studies have examined transcatheter mitral VinV or VinR, with the largest number of cases reported to date using the Edwards system.
4. The mechanism of valve dysfunction must be clearly determined. Transesophageal echocardiography should be performed in patients with significant regurgitation to exclude paravalvular regurgitation or endocarditis as an etiology. Echocardiograms must also be reviewed to confirm that any stenosis is due to cusp dysfunction and not patient-prosthesis mismatch.
5. Aortic VinV procedures can be associated with risk of coronary obstruction, particularly with stentless bioprosthetic aortic valves. Careful procedural planning and monitoring are important to minimize this risk.
6. The utility of balloon pre-dilation is controversial, as it may increase risk of embolization of friable material from degenerated valves.
7. Optimal positioning of the transcatheter device for VinV implantation is critical. The narrowest portion of all surgical valves is at the level of the sewing ring, which should be used as a reference for positioning. Images are provided in the figures for several common valves.
8. Compared to transcatheter valve implantation in a native aortic valve, the VinV procedure is associated with an increased risk of valve malpositioning/embolization and coronary obstruction, and lower rates of pacemaker implantation.
9. Post-procedural gradients are higher with aortic VinV procedures compared to placement in native stenotic aortic valves.
10. Transcatheter VinR procedures require accurate knowledge of the prior device. The noncircular shape of annuloplasty rings may result in paravalvular regurgitation, particularly if does not deform to the shape of the transcatheter device. Another possible complication of mitral VinV or VinR implantation is left ventricular outflow tract obstruction.

Keywords: Aortic Valve Stenosis, Bioprosthesis, Cardiac Surgical Procedures, Constriction, Pathologic, Echocardiography, Transesophageal, Echocardiography, Endocarditis, Heart Defects, Congenital, Prostheses and Implants, Thrombosis, Tomography, Tomography, X-Ray Computed

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