Case report: combined transcatheter paravalvular leak closure and valve-in-valve transcatheter aortic valve replacement for treatment of severe regurgitation complicating transcatheter aortic valve replacement.

Background: Concurrent transvalvular regurgitation (TVR) and paravalvular leak (PVL) complicating transcatheter aortic valve replacement (TAVR0 is rare, and optimal management is not well described. Case Summary: A 74-year-old man with LVEF of 40% and prior TAVR (34-mm Medtronic Evolut) presented 8 years post-implantation with New York Heart Association (NYHA) class IV acute decompensated heart failure. Transthoracic echocardiography (TTE) identified severe bioprosthetic aortic regurgitation; transoesophageal echocardiography (TEE) delineated concomitant severe TVR and PVL. Computed tomographic angiography (CTA) identified a discrete paravalvular tunnel between two calcific annular nodules. Given the prohibitive surgical risk, he underwent single-session transcatheter PVL closure with an Amplatzer ductal occluder followed by valve-in-valve TAVR with an Edwards SAPIEN 3 Ultra RESILIA valve. AR pressure half-time improved from 217 to 436 ms, and invasive aortic diastolic pressure normalized from approximately 40-65 mm Hg. At 30-day follow-up, symptoms had improved to NYHA class II, with trace residual PVL and no TVR on TTE. Discussion: To the best of our knowledge, this represents one of the first reported cases of a combined single-session percutaneous approach, consisting of transcatheter PVL closure and valve-in-valve TAVR, to address mixed-mechanism bioprosthetic aortic regurgitation. TEE and CTA are essential for mechanism delineation. A combined transcatheter approach is feasible and effective in high-risk patients.