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

Figure 2. Transcatheter aortic valve implantation concomitant with percutaneous edge-to-edge mitral valve repair in a 70-year-old
male patient with severe symptomatic aortic stenosis and severe degenerative mitral regurgitation due to posterior leaflet prolapse
(the first 3 images). The procedure was started by the transseptal puncture, followed by transfemoral implantation of a 29-mm
balloon-expandable Edwards SAPIEN 3 valve. The last step was MitraClip implantation under transesophageal echocardiogram and
angiographic control

If a double-valve transcatheter replacement is indicated since the majority of the mitral devices are
[29]
delivered transapically, a simultaneous approach through the same access can be used . Regarding the
best order, usually the aortic valve is performed first. The rationale for this strategy is that, since the aortic
[30]
and mitral annuli are contiguous, bridged by the aorto-mitral fibrous curtain , some degree of obstruction
[29]
for the new aortic valve deployment can happen if the mitral is treated first . This same order has been
[31]
adopted during transapical TAVI simultaneous with NeoChord implant .
In the case of TAVI combined with percutaneous edge-to-edge mitral valve repair, a common strategy is
to start with the transseptal puncture under partial anticoagulation, followed by TAVI delivery under full
anticoagulation, finalizing with the percutaneous mitral valve repair [Figure 2]. To minimize the time with
a large device in the iliofemoral system, the arterial sheath can be removed before starting the mitral valve
[25]
procedure .
Last but not least, some reports have also supported TAVI combined with valve-in MAC (mitral annular
calcification), either by transfemoral/transseptal or transapical access [32,33] .

Summarizing current data, a systematic review of combined aortic [TAVI or transcatheter aortic valve-
in-valve (TAViV)] and mitral valve interventions [transcatheter mitral valve replacement (TMVR),
transcatheter mitral valve-in-valve/valve-in-ring (TMViV/ViR), or percutaneous mitral valve repair
(PMVR)], involving 60 patients from 37 studies, showed that the main reason for combined approach was
severe AS (92%) associated with moderate/severe MR (65%). In the majority of the cases, the aortic valve
intervention was performed before the mitral valve. Mortality rates were 25% for TAVI plus TMVR, 17% for