Triple trouble: three valve-in-valve in a challenging case of systemic lupus erythematosus

A 78-year-old lady affected by systemic lupus erythematosus (SLE) underwent mitral, tricuspid, and aortic valve replacement with 25 mm Perimount, 27 mm Perimount, and 19 mm Perimount bioprosthesis, respectively (panel A), at an external hospital 8 years ago. She was admitted with dyspnoea on exertion and oedema of both lower limbs. The emergency echocardiography revealed structural valve deterioration in all bioprostheses (panel B).1 Considering an underestimated high surgical risk (EuroSCORE II, 20.22%), the Heart Team decided to perform valve-in-valve (ViV) therapy to avoid the open surgical procedure. The patient then received transcatheter aortic valve implantation (TAVI) through the right femoral access. A 23-mm Evolute pro prosthesis (Medtronic) was released in the aortic positions, resulting in no paravalvular leak, no obstruction in the coronary arteries, nor conduction block. One month later, with the preoperative evaluation (panel G-J) and simulating the puncture site of the interatrial septum (panel E, F), two 26-mm Sapien 3 prosthesis (Edwards Lifesciences) were released in the mitral (panel C) and tricuspid positions (panel D). The patient was discharged a week later, and the follow-up echocardiography showed no leaks and low gradients. Bioprosthetic valve failure remains a major clinical challenge, particularly in patients with multiple comorbidities.