An 81-year-old male patient, who underwent concomitant surgical mitral and tricuspid valve repair at the age of 71, presented with symptomatic dyspnea NYHA class III and angina to our outpatient department. Clinical examination revealed signs of low forward cardiac output with pulmonary and peripheral edema. After admission, the patient was stabilized by intravenous diuretics and oxygen support.

Transthoracic and transesophageal echocardiography (TEE) revealed severe recurrent mitral regurgitation and concurrent severe aortic valve stenosis (valvular orifice areaof 0.51 cm2 and low-flow low-gradient stenosis. In addition, the right ventricle ejection fraction was only at 35%, indicating impairment, coupled with the presence of pulmonary hypertension (RVSP 85mmHg). MSCT analysis showed the aortic annulus area is 519mm2, and the neo-LVOT are is 218mm2.

Coronary angiography showed patent coronary, and the risk of coronary obstruction was relative low.

1. A Sentinel cerebral protection device was deployed first. 2. After a successful atrial septal puncture, Tip-to-base LAMPOON was performed to prevent LVOT obstruction. 3. The S3 29 mm was introduced and deployed under rapid ventricular pacing, aiming for a 90% ventricular position and 10% atrial stent position. 4. TEE showed severe PVL even after post-dilatation.5. Another 29mm S3 was deployed consecutively, and the PVL was sealed completely. 6. For aortic stenosis, a 34mm Medtronic Evolut R was then implanted with fast pacing for valve positioning and release. 7. Valve infolding was discovered by TEE, and was fixed after post-dilatation.

This case adds to the body of evidence showing feasibility and safety of simultaneous multivalvular intervention procedures with contemporary balloon-expandable and self-expanding TAVRs via a transfemoral approach. To achieve optimal results, meticulous CT-based procedure planning is important.