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Tagliari et al. Vessel Plus 2020;4:16 I http://dx.doi.org/10.20517/2574-1209.2020.05 Page 3 of 12

Figure 1. Transcatheter aortic valve implantation simultaneous to percutaneous coronary intervention in an 81-year-old female
patient with severe symptomatic aortic stenosis and severe proximal left anterior descending coronary artery stenosis. In this patient,
percutaneous coronary intervention using 2 drug-eluting stents was performed first, followed by transfemoral implantation of a 26-mm
balloon-expandable Edwards SAPIEN 3 valve

should take into account patient clinical conditions, CAD burden, and the amount of myocardium at
[10]
[12]
risk . Penkalla et al. suggested some additional anatomical criteria, as follows: (1) left main coronary
artery stenosis > 50%; (2) coronary stenosis of 90% or more in the proximal or mid-left anterior descending
coronary artery; or (3) coronary stenosis of 90% or more in the proximal or mid-right coronary artery (if
dominant artery); or (4) coronary stenosis of 90% or more in the proximal or mid-left circumflex artery (if
dominant).

MITRAL VALVE INTERVENTIONS
Moderate or severe mitral regurgitation (MR) is present in 22% to 48% of patients with severe AS
[1,2]
undergoing TAVI [17-20] , particularly in those inoperable or at high-risk . These individuals constitute a
particular subgroup that could benefit from combined transcatheter interventions.

Although few studies have suggested that MR is not an independent predictor of mortality after TAVI [20,21] ,
the majority of authors point out a significant increase in mortality risk if moderate to severe MR is present
at the time of TAVI [22-24] .

Among the factors that should tailor indication of combining TAVI with an MR intervention are the
following: individual patient’s characteristics such as age, comorbidities, life expectancy, and frailty; valve
characteristics such as MR severity and etiology; together with some technical aspects and procedural
risks [10,25] .

MR etiology is a particularly important issue since a less aggressive management could be indicated in
the setting of functional MR, assuming that some improvement in MR severity is expected to occur after
TAVI [26,27] . Thus, a staged approach may be reasonable, with the aortic valve being addressed first, and the
mitral valve treated only in those who remain symptomatic in spite of a successful TAVI. On the contrary,
in the setting of a predominantly primary MR, as structural valve alterations are not expected to improve,
bivalvular interventions should be advocated [25,28] .