Sequential transcatheter valve-in-valve procedures across three valve positions: Transseptal valve-in-valve mitral implantation following aortic valve-in-valve and EVOQUE™ tricuspid replacement – a case report and short-term outcomes

Structural valve degeneration of bioprosthetic heart valves is a growing challenge in elderly patients with prior surgical valve replacements. Transcatheter valve-in-valve (ViV) procedures have emerged as an effective treatment option for high-risk patients with failing bioprostheses. We report the case of an 84-year-old female patient with progressive mitral stenosis and regurgitation following biological mitral and aortic valve replacement (2008), who had previously undergone ViV transcatheter aortic valve replacement (2023) and transcatheter tricuspid valve replacement using an EVOQUE™-system (Edwards Lifesciences, Irvine, CA, USA) (2024). Most recently, degeneration of the mitral bioprosthesis led to progressive dyspnea and heart failure symptoms. Due to high surgical risk (EuroSCORE-II 13.3%), a transseptal mitral ViV procedure was performed using a SAPIEN S3 Ultra Resilia™ valve (Edwards) with excellent procedural outcomes [mean pressure gradient 6 mmHg, no paravalvular leak, neo left ventricular outflow tract (neoLVOT) assessment 254 mm 2 ]. At two-month follow-up, hemodynamic parameters remained stable with preserved left ventricular ejection fraction (50% biplane) and sustained symptomatic improvement (New York Heart Association Class I). This case demonstrates the feasibility and safety of transcatheter ViV interventions in complex, multi-valve bioprosthetic degeneration, highlighting specific technical considerations including computed tomography-based neoLVOT assessment and management of prosthesis-prosthesis interactions. Learning objective This case demonstrates feasibility of sequential transcatheter valve replacements across three valve positions in high-risk patients using computed tomography-guided planning (neoLVOT ≥200 mm 2 ). Critical learning points: 1.EVOQUE™ tricuspid replacement might increase transseptal puncture complexity but does not contraindicate mitral access. 2.Comprehensive hemodynamic assessment (heart rate, blood pressure, effective orifice area) is challenging in multivalvular heart disease due to changing flow volumes across diseased and prosthetic valves. 3.Long-term surveillance is needed in complex multivalvular heart disease.