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Background: Transcatheter valve-in-valve (VIV) implantation evolved as a therapeutic alternative, despite an increased risk of coronary obstruction in comparison with a regular transcatheter aortic valve implantation (TAVI). We report a comprehensive single-institution experience emphasizing strategies to reduce the risk of myocardial ischemia., Methods: Since 2009, 639 patients underwent a TAVI procedure in our institution. All patients are prospectively collected into an institutional registry. In total 31 patients underwent a VIV procedure at our institution (age 77.8 ± 6.3 years; The Society or Thoracic Surgeons predicted risk of mortality 20.9% ± 8.8%; New York Heart Association (NYHA) 3.0 ± 0.6). Degenerated bioprostheses included 24 Mitroflow, 6 Edwards Perimount, and Cryo-Valve O' Brien with label sizes from 21 to 27 mm. The type of failure was mostly regurgitation with or without concomitant stenosis (78%)., Results: Patients were provided with 5 Medtronic CoreValves, 15 Edwards SapienXT, 1 Edwards Sapien 3, 7 Medtronic Engager, and 3 Symetis Acurate TA valves. The procedural success rate was 88%. The left main stem was occluded in 1 patient (Sapien XT 26 in a Mitroflow 25 mm) who underwent emergent revascularization. Two patients suffering from a degenerated Mitroflow prosthesis needed a second valve (Sapien XT). Two patients with a degenerated Mitroflow prosthesis treated with a Sapien XT developed postprocedural myocardial ischemia and deceased on postoperative days 1 and 2, accounting to an overall incidence of coronary insufficiency associated to the VIV procedure of 10%. With the introduction of valves allowing commissural alignment (Acurate TA) and leaflet capturing as well (Engager) no further coronary insufficiency occurred. The mean gradient decreased significantly from 39.3 ± 14.0 to 16.1 ± 7.2 mm Hg (p = 0.002). Post-procedural regurgitation was classified as trace in 7 patients (23%) and moderate in 4 patients (13%). The 30-day survival was 77% with a significantly improved NYHA class of 1.79 ± 0.58 (p = 0.001)., Conclusions: Jeopardizing coronary blood flow is likely in stenotic and calcified bioprostheses, particularly in tubelike aortic sinuses. Planning, imaging, and the use of valves allowing commissural alignment as well as leaflet capturing seem to reduce the risk. Further studies are necessary to support this hypothesis., (Copyright © 2015 The Society of Thoracic Surgeons. Published by Elsevier Inc. All rights reserved.)