according to the euro heart survey on valvular heart disease , aortic stenosis ( as ) is the most frequent and mitral stenosis ( ms ) is the least frequent among native single - sided valve diseases in europe ( 43.1% vs. 12.1% ) . in as , the most common etiology is degenerative , and the least common etiology is rheumatic ( 81.9% vs. 11.2% ) , whereas in the case of ms , the situation is just the opposite , rheumatic being the most common and degenerative being the least common etiology ( 85.4% vs. 12.5% ) .
patients with the combination of severe and symptomatic degenerative as and severe symptomatic degenerative ms are very rare , and there is a lack of data about their frequency in the literature . according to the current european guidelines on the management of valvular heart disease , transcatheter aortic valve implantation ( tavi ) is recommended in patients with severe symptomatic as , who are considered unsuitable for conventional surgery because of severe comorbidities .
likewise , percutaneous mitral balloon commissurotomy ( pmc ) is recommended in patients with severe symptomatic ms , who are unsuitable for surgery .
we discuss a rare case of an elderly patient with the combination of severe degenerative symptomatic as and symptomatic ms , who was found unsuitable for surgical treatment by the heart team due to several comorbidities including severe obesity .
she was considered also unsuitable for two - time general anesthesia in the case of two - step single - valve percutaneous approach by the anesthesiologists and was subsequently offered a percutaneous dual - valve treatment in a single intervention ( tavi and pmc ) . according to our knowledge , this is the first case of this kind described in the literature .
a 76-year - old female patient with the combination of severe symptomatic degenerative as and severe symptomatic degenerative ms was admitted because of acute worsening of heart failure . at the time of presentation , the patient was new york heart association ( nyha iii ) with bilateral peripheral edema and the signs of left - heart failure .
moreover , the patient suffered from chronic ischemic heart disease ( myocardial infarction 20 years earlier ) , underwent coronary artery bypass grafting ( 17 years earlier ) , stent implantation in saphenous vein graft to first diagonal branch , and the left anterior descending artery ( 7 years earlier ) .
the patient was also diabetic ( oral treatment ) and suffered from chronic kidney failure ( kdigo type iiia ) , dyslipoproteinemia , sleep - apnea syndrome , and had severe obesity ( body mass index of 53.3 ) .
baseline diagnostics included coronary angiography [ figure 1 ] , transesophageal echocardiography ( tee ) [ figures 2 and 3 ] , and computed tomography angiography ( cta ) .
( a ) left anterior descending occlusion , 80% ostial intermediate and left circumflflex stenosis , patent saphenous vein graft to intermediate and first obtuse marginal .
lad : left anterior descending , i m : intermediate , lcx : left circumflflex , svg : saphenous vein graft , om1 : first obtuse marginal , rca : right coronary artery , cto : chronic total occlusion , pda : posterior descending artery , d1 : first diagonal branch transesophageal echocardiography before intervention - aortic valve .
( b ) peak aortic jet = 4.5 m / s , mean pressure gradient = 49 mmhg , aortic valve area = 0.78 cm ( ejection fraction = 50% ) transesophageal echocardiography before intervention - mitral valve .
( c ) three - dimensional echocardiography of joined leaflflets creating two orifices ( a1 and a2 ) .
al : anterior leaflflets , pl : posterior leaflflets , la : left atrium , lv : left ventricle , mv : mitral valve with an euroscore ii of 16% , the patient was classified as high risk and due to concomitant comorbidities , the heart team found her unsuitable for surgery and repeated general anesthesias . before intervention , the patient was scheduled for computed tomography for detailed analysis of aortic root and peripheral arteries .
the analysis and measurements were done using the 3mensio software , valve and vascular modules ( 3mensio medical imaging bv , bilthoven , the netherlands ) . based on the detailed analysis of all imaging modalities ,
the strategy was to perform dual - valve single - intervention with pmc - inou balloon ( toray , tokyo , japan ) as the first step , followed by tavi - right femoral approach and 26 mm corevalve ( medtronic , minneapolis , mn , usa ) .
pmc and tavi were performed under the angiographic and tee guidance [ figure 4 ] with no periprocedural complications .
postintervention tee showed an excellent result of pmc with a residual transmitral gradient of 2 mmhg and mild regurgitation [ figure 5 ] , and an excellent result of tavi ( normal pressure gradient over the corevalve and no remaining aortic regurgitation ) .
the proper position and apposition of corevalve were also confirmed with postinterventional cta [ figure 6 ] .
postinterventional course was uneventful , free of complication , and the patient was discharged on day 4 . at 6-months clinical follow - up ,
the patient is stable , compensated and nyha i. dual - valve single - intervention .
lv : left ventricle , la : left atrium , mv : mitral valve , ao : aorta , * : inou balloon transesophageal echocardiography control . ( a ) successful resolution of mitral stenosis .
( d ) absence of corevalve regurgitation ( arrow ) computed tomography angiography control after dual - valve intervention .
( d ) three - dimensional reconstruction of the thorax with a clearly visible corevalve. ao : aortic
the first - in - man case of tavi for the treatment of severe degenerative as was described by cribier et al . in 2002
. a 57-year - old very high - risk patient ( cardiogenic shock , subacute leg ischemia , and several other noncardiac comorbidities ) was found unsuitable for surgery and underwent successful tavi .
four - month follow - up showed satisfactory valvular function ; however , the patient died soon after for noncardiac reasons .
implantation techniques and devices improved since then and tavi became the standard of treatment for the patients with severe as , who are unsuitable for surgery . with the aging population and the fact that degenerative as is the most frequent type of valvular disease , we can expect the rise in the number of tavi procedures in the near future . moreover , cribier et al .
have shown noninferiority of tavi to surgery and the first reports of the corevalve us pivotal study 2-year results in high - risk patient population show superior results to surgery , which suggests in the direction of possible superiority of tavi in all subsets of patients . clinical trend to treat low- or intermediate - risk patients
is already established in many experienced centers , however , for tavi to become the method of choice also in patients with severe as , who are otherwise suitable surgical candidates , we need to wait for long - term results of the partner ii and surtavi trials . on the other hand ,
severe ms is a very rare disease in the western world , and most of the cases are rheumatic in etiology .
according to the guidelines , pmc should remain the first choice of treatment in symptomatic patients who are unsuitable for surgery and in younger patients where postponing the surgery is desirable .
have confirmed good long - term results of pmc in the group of patients with rheumatic ms ; on the other hand , tuzcu et al .
have shown that pmc is not the best option of treatment for nonrheumatic ms . in the case of our high - risk patient , who was unsuitable for surgery or two - time anesthesia in the case of two - step single - valve percutaneous approach ,
dual - valve single - intervention ( pmc and tavi ) proved to be a feasible and successful choice of treatment , allowing the patient to improve from nyha iii at the time of presentation to nyha i at the time of discharge and to remain in the same good condition at a 6-month follow - up .
 aortic stenosis is the most frequent and mitral stenosis is the least frequent native single - sided valve disease in europe . 
 patients with the combination of severe symptomatic degenerative aortic and mitral stenosis are very rare . 
 guidelines for the treatment of heart valve diseases are clear for single - valve situations . 
 however , there is no common agreement or recommendation for the best treatment strategy in patients with multiple valve disease and severe concomitant comorbidities . a 76-year - old female patient with the combination of severe degenerative symptomatic aortic and mitral stenosis and several comorbidities including severe obesity , who was found unsuitable surgical candidate by the heart team and unsuitable for two - time general anesthesia in the case of two - step single - valve percutaneous approach by anesthesiologists , underwent successful percutaneous dual - valve single - intervention ( transcatheter aortic valve implantation and percutaneous mitral balloon commissurotomy ) . 
 percutaneous dual - valve single - intervention is feasible in selected symptomatic high - risk patients . 