65-year-old male presented with 3-month history of shortness of breath, bilateral pedal oedema, ascites and recurrent hospitalization for heart failure. He had mitral valve replacement- mechanical plus tricuspid annuloplasty in 2010. His risk profile included atrial fibrillation, COPD, seizure disorder, chronic liver disease, low body weight (36kg,BMI-15.6kg/m2), and recent subdural hematoma with burr hole evacuation. Examination showed anasarca and pulmonary oedema 

ECG- Atrial fibrillationChest X-ray: Cardiomegaly,bilateral pleural effusion, pulmonary congestionECHO- Echo- Mitral prosthetic valve function- normal,paravalvular leak, defect measuring 2.5-3mm. Severe tricuspid regurgitation [vena contracta - 10mm; Regurgitant volume- 79ml]Tricuspid valve leaflets thickened, restricted opening. Mean transtricuspid gradient - 6mmHg. Severe aortic valve stenosis, significant regurgitation

Coronary angiogram - no significant diseaseMean pulmonary artery pressure-30mmHgNo significant transmitral gradientV wave amplitude > 25mmHg in RA tracing
DiagnosisAortic stenosis and regurgitation of rheumatic etiologyMitral paravalvular leak Tricuspid regurgitation with restricted opening

Treatment plan A:    Surgical repair of mitral paravalvular leak, aortic and tricuspid valve replacement •      Declined by surgeons in view of co-morbidities and high operative risk. Hence treatment plan B outlined below was considered Treatment plan B:  Staged procedure •      Stage1: Closure of mitral paravalvular leak with a duct occluder, transcatheter aortic valve implantation (TAVI) and balloon tricuspid valvuloplasty (Regurgitation already severe, valvuloplasty to relieve restriction) •      Stage2 (A week later): Bicaval valve (TRIC)implantation for tricuspid valve- But inferior vena caval (IVC) Valve of TRIC embolized to right atrium in recovery room, it was retrieved surgically, surgical IVC valve implantation attempted but not possible. CT review of IVC-hepatic vein anatomy showed 

• Large IVC diameter at RA junction as compared to infra hepatic segment IVC diameter
• Short hepatic vein to right atrial distance

 A month later, an anchoring stent (‘anti-slip’) was implanted within IVC and then IVC component of TRIC valve was successfully deployed within it. 

What we learned from our experience?* Valvular heart disease patients may present with valve defects of heterogeneous etologies* Surgical strategy-the gold standard for multivalvular pathologies may not be feasible in all patients, hence interventional treatment modalities may need to be considered that may be staged* Bi-Caval valve implantation can be challenging. Adequate CT planning and preparation is a must. Always make sure sufficient hardware/ adequate size second valve is available in the lab* Pre-stenting can help in successful valve anchor of caval valves and prevent embolization in challenging anatomies