Simultaneous TAVR and TMVR-in-MAC Guided by 3D Modeling and Prosthesis Modification: A Case Report

Background Severe aortic stenosis (AS) with concomitant mitral annular calcification (MAC) presents substantial procedural and surgical challenges, and simultaneous transcatheter treatment remains rare. This case adds to the emerging literature by demonstrating a hybrid approach using transfemoral TAVR and transapical TMVR-in-MAC supported by patient-specific 3D-printed simulation and prosthesis modification. Case Summary A 68-year-old woman with severe obesity, diabetes, chronic kidney disease, prior thoracic surgery, and a pacemaker presented with progressive dyspnea. Echocardiography showed severe aortic stenosis and functional mitral stenosis due to extensive MAC. Given prohibitive surgical risk, the Heart Team pursued a percutaneous strategy. A transfemoral self-expanding aortic THV was partially deployed for annular anchoring, followed by transapical TMVR with a balloon-expandable valve modified with a polyethylene terephthalate (PET) skirt. Pre-procedural simulation with a patient-specific 3D-printed model guided implant depth and informed the decision for prosthesis modification. Both valves were implanted successfully with no paravalvular leak; a moderate LVOT gradient was noted. Discussion Simultaneous TAVR and TMVR in MAC is rare and technically challenging. This case shows that patient-specific 3D-printed modeling can support procedural planning and device modification, enabling a feasible hybrid transcatheter strategy with favorable clinical outcomes in a high-risk patient. adjunct to hybrid transcatheter solutions for high-risk patients with complex dual-valve disease.