Single-Session Transcatheter Aortic and Tricuspid Valve-in-Valve Implantation in a Patient with Prior Multivalve Surgery and a Chronic Transvenous Pacing Lead: A Case-Based Review of Procedural Strategy

Abstract

Background: The population of patients surviving previous multivalve surgery is expanding, and structural Heart Teams increasingly encounter complex multivalvular disease requiring reintervention, for which redo surgery carries prohibitive risk. Patient selection, sequential procedural planning, prosthesis choice, and, in particular, pacing strategy and protection of pre-existing intracardiac hardware remain unstandardized. Case Presentation: We report a 73-year-old woman with a twenty-year history of rheumatic multivalvular heart disease, comprising mechanical mitral valve replacement, tricuspid annuloplasty and pacemaker implantation, redo bioprosthetic tricuspid valve replacement, and critical native aortic stenosis combined with severe bioprosthetic tricuspid regurgitation. After multidisciplinary Heart Team evaluation, the patient underwent successful single-session, sequential transfemoral transcatheter aortic valve implantation followed immediately by tricuspid valve-in-valve implantation using a reversed balloon-expandable valve and a dedicated biventricular guidewire pacing strategy. The sequential interventions achieved immediate hemodynamic success with no lead dysfunction, paravalvular leak, or other acute complications. Review: Using this case as a clinical anchor, we present a focused, case-based review of contemporary evidence on single-session double-valve transcatheter intervention. We address patient selection, procedural sequencing, imaging, prosthesis choice, and management of chronic transvenous pacing leads, providing a practical decision-making algorithm to guide Heart Teams in similarly complex scenarios. Conclusions: Individualized, multidisciplinary Heart Team planning, including a dedicated biventricular guidewire strategy, can simplify sequential transcatheter treatment of multivalvular disease in patients with pre-existing intracardiac hardware. This case-based review provides a pragmatic, hypothesis-generating framework to support clinical decision-making as the body of evidence for combined double-valve transcatheter interventions continues to evolve.