How Should I Manage a Challenging Aortic Prosthesis Angle During Valve-in-Valve Implantation?

Valve-in-valve TAVR procedure stalled due to challenging aortic to prosthesis angle not allowing the advancement of the Evolut R into the failing 25 mm Magna prosthesis. Efforts to better align the TAVR device with the valve prosthesis by using conventional methods failed. Eventually, a buddy wire allowed advancement and successful deployment of the Evolut R 26 mm within the stenosed surgical valve. The role and methodology of buddy wire use in TAVR, valve-in-valve procedures (first report) and structural heart procedures is reviewed.