Simultaneous Transcatheter Aortic and Tricuspid Valve-in-Valve Implantation in a Patient with Prior Multivalve Surgery and a Chronic Transvenous Pacing Lead: A Case-Based Review of Procedural Strategy

Background: The population of patients surviving previous multivalve surgery is expanding, and structural Heart Teams increasingly encounter complex, multivalvular disease requiring reintervention, for which redo surgery often carries prohibitive risk. Combined, single-session transcatheter treatment of two diseased valves is increasingly reported, but patient selection, procedural sequencing, prosthesis choice, and, in particular, pacing strategy and protection of pre-existing intracardiac hardware remain largely unstandardized. Case Presentation: We report a 73-year-old woman with a twenty-year history of rheumatic multivalvular heart disease, comprising mechanical mitral valve replacement, tricuspid annuloplasty and pacemaker implantation in 2006, redo bioprosthetic tricuspid valve replacement in 2019, and, in 2026, critical native aortic stenosis combined with severe bioprosthetic tricuspid stenosis. After multidisciplinary evaluation, the patient underwent single-stage transfemoral transcatheter aortic valve implantation (TAVI) followed immediately by tricuspid valve-in-valve implantation using a reversed balloon-expandable valve, with dedicated stiff guidewires positioned in each ventricle before device deployment and used as combined delivery-and-pacing platforms. Both procedures were successful, with no lead dysfunction, paravalvular leak, or other complications. Review: Using this case as a clinical anchor, we review contemporary evidence on simultaneous double-valve transcatheter intervention, addressing patient selection, the rationale for simultaneous versus staged treatment, valve sequencing, procedural planning, prosthesis choice, pacing strategies — including guidewire-based and leadless pacing — and management of permanent pacing leads, and propose a practical decision algorithm to guide Heart Team planning in similarly complex patients. Conclusions: Individualized, literature-informed Heart Team planning, including a dedicated biventricular guidewire strategy, can simplify combined transcatheter treatment of multivalvular disease in patients with pre-existing intracardiac hardware; this review provides a structured framework to support such planning as the evidence base for combined double-valve transcatheter intervention continues to grow.