The first in-silico simulation of Evolut-in-Evolut TAVR: reproduction of a real clinical scenario

Our clinically validated computational framework developed to virtually replicate TAVR in patient-specific anatomies was adapted for this TAV-in-TAV procedure. This is the first in-silico simulation reproducing a redo TAVR with two Evolut prostheses. The patient-specific anatomy was reconstructed from CT scans. The virtual prostheses were positioned in the aortic root, and the simulation was then validated against post-operative imaging, confirming its accuracy. In addition, a post-implantation computational fluid dynamics (CFD) simulation was performed to evaluate post-operative paravalvular leakage (PVL) and coronary obstruction. Although retrospective, this analysis provided valuable procedural insights, notably highlighting reasons for suboptimal implantation outcomes, such as prosthesis underexpansion, as well as confirming absence of residual PVL and coronary obstruction after the second implant. The potential of prospective simulations lies in supporting device choice and placement strategies to improve outcomes. These patient-specific simulations allow testing of various devices, sizes, and orientations to identify the optimal approach.