Staged TAVR and TEER for complex multivalvular disease in advanced heart failure: a case report

BACKGROUND: Multivalvular heart disease complicated by advanced heart failure in elderly patients represents a major therapeutic challenge, particularly in the presence of complex anatomy, severe ventricular remodeling, and high surgical risk. Staged transcatheter strategies may offer a less invasive and individualized therapeutic alternative. An elderly patient with end-stage heart failure and severe ventricular remodeling was diagnosed with Sievers type I bicuspid aortic valve with mixed stenosis and severe regurgitation, complicated by functional moderate-to-severe mitral regurgitation. Given the patient's high surgical risk (STS-PROM 12%; EuroSCORE II 15%), a staged transcatheter strategy was adopted. Transfemoral TAVR was first performed with good prosthetic valve function and clinical improvement. Due to persistent symptomatic functional MR, subsequent transcatheter edge-to-edge repair (TEER) was performed three months later, resulting in significant MR reduction, symptomatic improvement, and favorable hemodynamic outcomes at follow-up. DISCUSSION: This case demonstrates the feasibility and clinical value of a staged transcatheter strategy in high-risk elderly patients with complex multivalvular disease and advanced heart failure. Sequential intervention allows reassessment of residual valve pathology, reduces procedural complexity, and lowers procedural risk compared with simultaneous multivalvular intervention. TAKE-HOME MESSAGE: A staged transcatheter strategy combining TAVR followed by TEER represents a safe, feasible, and effective therapeutic option for selected high-risk patients with complex multivalvular disease and advanced heart failure, offering individualized treatment and meaningful symptomatic improvement when surgical risk is prohibitive.