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Tagliari et al. Vessel Plus 2020;4:16 I http://dx.doi.org/10.20517/2574-1209.2020.05 Page 5 of 12

TAVI plus TMViV/ViR, 0% for TAViV plus TMViV/ViR, and 15% for TAVI/ViV plus PMVR. Significant
[29]
post-procedure paravalvular leak was rare in all combinations .

It is also important to remember some caveats regarding MR evaluation in the presence of AS. MR jet
[34]
velocity can be increased due to high left ventricular pressures , while AS transvalvular gradient and flow
[35]
can be hampered by the presence of MR .

TRICUSPID VALVE INTERVENTIONS
Significant tricuspid regurgitation (TR) is diagnosed in about 10% of patients with severe AS, and usually
indicates right ventricular dysfunction [36,37] .

Although severe TR has been associated with high mortality in patients with concomitant severe AS
conservatively treated, some authors have suggested that moderate or severe TR can improve after
TAVI [17,38] . Contradicting this idea, others have argued that TR will persist and that it is independently
associated with increased mortality following TAVI [17,39,40] .

To clarify the true impact of TR in patients with severe AS undergoing TAVI, a recent meta-analysis
evaluated 12 studies enrolling 41,485 TAVIs. Early and mid-term mortality were 1.80- and 1.96-fold
increased, respectively, in the presence of significant TR (OR = 1.80, 95%CI: 1.01-3.19; OR = 1.96, 95%CI:
[41]
1.35-2.85) . These findings were similar to those reported by Pavasini et al. , whose study demonstrated
[40]
a 2.0-fold increase in all-cause mortality if moderate to severe TR was present after TAVI (95%CI: 1.52-2.91).
The authors’ conclusion was that a more detailed and shared TR severity evaluation would be necessary to
understand its impact and the need for a combined approach in patients undergoing TAVI.

[42]
Opposing the above-mentioned statements, Barbanti et al. showed that, in patients with moderate to
severe TR submitted to TAVI, all-cause mortality risk was higher only in the presence of left ventricular
ejection fraction > 40%, suggesting that in patients with severely depressed ejection fraction, severe TR is
rather a surrogate marker of advanced disease than a real cause of worse outcomes.

[43]
Regarding the feasibility of combined approaches, in 2017, Reichart et al. described a successful case of
concomitant TAViV and tricuspid valve-in-ring using a 23-mm self-expanding transcatheter bioprosthesis
in aortic position and a 29-mm balloon-expandable transcatheter bioprosthesis in tricuspid position. The
authors highlighted that, for the rapid ventricular pacing maneuver, external pacemaker patches were used
to avoid the lead crossing through the tricuspid valve. Another option could be the use of a temporary lead
[44]
[45]
inserted through the coronary sinus or pacing over the left ventricular guidewire .
[46]
Another appealing case was reported by Abdi et al. , who combined TAVI with tricuspid valve-in-valve in
a patient with rheumatic heart disease. The balloon-expandable valve implanted in tricuspid position was
oversized by about 20% relative to the internal diameter of the previous bioprosthesis. The authors stressed,
however, that an excessive oversizing may impair leaflet opening, leading to early valve degeneration.

Considering the above evidence, it is clear that the tricuspid valve is a relatively non-explored territory, but
a potential target for combined transcatheter approaches.

AORTA INTERVENTIONS
Abdominal aortic aneurysm occurs in around 6% of patients undergoing TAVI, a number that is increasing
[47]
due to population aging, especially because both conditions share similar risk factors .