BACKGROUND Bioprosthetic aortic valve degeneration can present as isolated regurgitant failure, and an eccentric jet may raise the transmitral gradient, mimicking mitral stenosis. CASE SUMMARY An 84-year-old man presented with acute heart failure 12 years after surgical aortic valve replacement. Echocardiography showed a degenerated Trifecta bioprosthesis with an immobile leaflet causing severe eccentric aortic regurgitation, whose jet impinged on the anterior mitral leaflet and produced severe functional mitral stenosis. Given high surgical risk, the heart team performed transfemoral valve-in-valve transcatheter aortic valve replacement. DISCUSSION Trifecta leaflet tear causes regurgitant rather than stenotic failure; an eccentric jet can raise the transmitral gradient independent of the Austin Flint murmur. Valve-in-valve transcatheter aortic valve replacement eliminated the regurgitation, improved leaflet mobility, and reduced the mean mitral gradient from 17 to 6 mm Hg, with complete symptom resolution. TAKE-HOME MESSAGE Eccentric aortic regurgitation can cause a reversible rise in transmitral gradient; treating it can resolve apparent mitral stenosis without mitral intervention.
OBJECTIVES We describe mechanical leaflet traversal as an alternative to electrosurgical traversal for BICORN during valve-in-valve transcatheter aortic valve replacement in a patient with unfavorable cardiac orientation and extreme bilateral coronary obstruction risk. KEY STEPS The ShortCut device created targeted basal splits in both coronary leaflets. The left coronary cusp split was crossed using a Pilot 100 guidewire (Abbott) and microcatheter with an EBU 3.5 guide catheter (Medtronic) and Agilis steerable introducer (Abbott) support. After balloon dilation, the left coronary cusp was translocated with an 18-mm True Dilatation Balloon (BD). A 20-mm SAPIEN 3 Ultra transcatheter heart valve (Edwards Lifesciences) was then advanced through the right coronary cusp split and deployed within the pre-existing 23-mm SAPIEN 3 valve (Edwards Lifesciences). POTENTIAL PITFALLS Mechanical traversal requires precise targeting. Leaflet translocation may cause embolization, severe aortic insufficiency, or hemodynamic compromise, requiring readiness for immediate valve deployment. TAKE-HOME MESSAGE Mechanical traversal may facilitate BICORN when cardiac rotation, unfavorable catheter trajectory, neosinus malalignment, eccentric coronary takeoffs, or leaflet fibrocalcification make electrosurgical traversal challenging.
