A 72 year old lady was referred for urgent aortic valve surgery (aortic valve replacement – AVR) for severe symptomatic calcific aortic stenosis in 2008. Additionally, she would require coronary artery revascularisation and tricuspid valve repair for concomitant coronary artery disease and severe tricuspid regurgitation.

Her predominant symptoms were exertional dyspnoea (New York Heart Association (NYHA) Class III), chest pain and dizziness. Past medical history included mechanical mitral valve replacement (MVR) in 2001, atrial fibrillation, peripheral vascular disease requiring intervention in 2000, and transsphenoidal hypophysectomy for acromegaly in 1996.

Transthoracic echocardiography (TTE) demonstrated an aortic valve area of 0.7 cm², mean aortic valve gradient 36 mmHg, and peak trans valvular velocity 4.1 m/s in the context of good left ventricular (LV) systolic function (Video 1.1; Fig. 1.4). TOE confirmed a stable bi-leaflet mechanical MVR with normal leaflet mobility (Video 1.2; Fig. 1.5). At both TTE and TOE, severe tricuspid regurgitation was measured and the right ventricle was noted to be dilated with preserved systolic function. Aortic root diameter was normal.

Exercise tolerance testing was indeterminate at a poor level of exercise. Cardiac catheterisation had shown stenoses in her right coronary artery (RCA) and left circumflex (LCx), but an unobstructed left main stem (LMS) and left anterior descending artery (LAD). Lung function tests and carotid Dopplers were normal, and the dental team had optimised dentition.

Following review by the cardiothoracic surgical team, the patient was considered too high risk for conventional AVR because of her previous mitral valve surgery, pulmonary hypertension and frailty. She was therefore discussed at a multidisciplinary team (MDT) meeting to assess suitability for TAVI. Despite ongoing symptoms, the patient was initially reluctant to undergo intervention and chose close clinic follow-up. Some 4 years later, in July 2012, after further symptomatic deterioration, she reconsidered this position and agreed to go ahead with treatment.

Repeat TTE showed that the valve had narrowed further with an area now measuring 0.6 cm². The patient was quoted the following risks for a TAVI procedure; 6–10 % mortality, 2–3 % risk of stroke, 5 % risk of requiring a permanent pacemaker, 5 % risk of access site complications, and a small risk of the need for renal replacement therapy.