Valve Function Research Articles

Aortic valve fenestrations: Macroscopic assessment and functional anatomy study.

Aortic valve fenestrations are defined as a loss of aortic valve leaflet tissue. They are a common but overlooked finding with unclear significance. The aim of this study was to investigate the varied functional anatomies of aortic valve fenestrations. A total of 400 formalin-fixed autopsied human hearts were macroscopically assessed and the function of the aortic valve of 16 reanimated human hearts were imaged using Visible Heart® methodologies. Aortic valve leaflet fenestrations were present in 43.0% of autopsied hearts (in one leaflet in 24.0%, in two leaflets 16.0%, in all leaflets 3.0%). Fenestrations were mostly present in left (25.5%) followed by right (23.3%) and noncoronary leaflet (16.3%). In 93.8% of cases, the fenestrations form clusters and were mainly located at the free edge of the leaflet in the commissural area (95.4%). Hearts with aortic valve fenestrations had significantly larger aortic valve diameters and aortic valve areas (p < 0.001). The average surface area sizes of fenestrations were 23.8 ± 16.6 mm2 , and the areas were largest for left followed by right and noncoronary leaflet fenestrations (p < 0.001). The fenestration areas positively correlated with donor age (r=0.31; p=0.02). Significant hypermobility and subjective weakening of the leaflet adhesion levels of the fenestrated regions were observed. In conclusion, fenestrations of the aortic leaflets are frequent, and their sizes may be significant. They occur in all age groups, yet their size increase with aging. Fragments of leaflets with fenestrations show different behaviors during the cardiac cycle versus unchanged areas.

Matched comparison between external aortic root support and valve-sparing root replacement

ObjectivesDifferences in indication and technique make a randomised comparison between valve-sparing root replacement (VSRR) and personalised external aortic root support (PEARS) challenging. We performed a propensity score (PS)-matched comparison of...

Planning of graft size and 3D reconstruction using virtual reality technique in aortic valve reimplantation.

To evaluate applicability and feasibility of the virtual imaging technology for diagnosis and planning of the aortic valve sparing procedure. Pre-operative electrocardiography-gated computed tomography images of 12 adult patients with aortic root pathology were used for 3D reconstruction of the aortic root geometry. The structural analysis was conducted with focusing on spatial architecture of key aortic root structures such as the three commissures, intervalvular triangles (IVT), as well as on morphology of the aortic root base (AoB) and of the sinotubular junction (STJ). In all included patients, the 3D mapping of aortic root (AoR) morphology was successfully performed. The pre-operative diameter of the AoB was 30.6 ± 2.6 mm and of the STJ 46.5 ± 7.5 mm (p < 0.001). Based on measured AoB diameter, the mean size of prosthesis used was 28.3 ± 1.37 mm. The planar arrangement of the three commissures was similar to an equilateral triangle where the three commissures were at similar distance for each individual sinus with 39.8 ± 6.64 mm for right, 37.5 ± 7.10 mm for left, and 39.2 ± 7.52 mm for non-coronary sinus (p = 0.72) subsequently. The similar height of the three IVT's with 32.6 ± 5.87 mm for right, 33.6 ± 6.14 mm for anterior, and 31.7 ± 5.83 mm for left IVT (p = 0.73) was suggestive for all three commissures being positioned in the same plane. Consequently at reimplantation, the orientation of the three commissures followed the pattern of an equilateral triangle. The reconstructed images revealed a detailed 3D anatomy of the aortic root, with the spatial arrangement of the intervalvular triangles, planimetric orientation of the commissures, as well as determination of the AoB and STJ diameters. Obtained information was successfully applied to pre-operative surgical planning. The reimplantation technique, the height of the reimplanted intervalvular triangles, as well as their orientation are crucial for achieving adequate aortic valve function.

Recent technologies in cardiac imaging.

Cardiac imaging allows physicians to view the structure and function of the heart to detect various heart abnormalities, ranging from inefficiencies in contraction, regulation of volumetric input and output of blood, deficits in valve function and structure, accumulation of plaque in arteries, and more. Commonly used cardiovascular imaging techniques include x-ray, computed tomography (CT), magnetic resonance imaging (MRI), echocardiogram, and positron emission tomography (PET)/single-photon emission computed tomography (SPECT). More recently, even more tools are at our disposal for investigating the heart's physiology, performance, structure, and function due to technological advancements. This review study summarizes cardiac imaging techniques with a particular interest in MRI and CT, noting each tool's origin, benefits, downfalls, clinical application, and advancement of cardiac imaging in the near future.

Multiple aspects of lymphatic dysfunction in an ApoE -/- mouse model of hypercholesterolemia.

Introduction: Rodent models of cardiovascular disease have uncovered various types of lymphatic vessel dysfunction that occur in association with atherosclerosis, type II diabetes and obesity. Previously, we presented in vivo evidence for impaired lymphatic drainage in apolipoprotein E null (ApoE -/- ) mice fed a high fat diet (HFD). Whether this impairment relates to the dysfunction of collecting lymphatics remains an open question. The ApoE -/- mouse is a well-established model of cardiovascular disease, in which a diet rich in fat and cholesterol on an ApoE deficient background accelerates the development of hypercholesteremia, atherosclerotic plaques and inflammation of the skin and other tissues. Here, we investigated various aspects of lymphatic function using ex vivo tests of collecting lymphatic vessels from ApoE +/+ or ApoE -/- mice fed a HFD. Methods: Popliteal collectors were excised from either strain and studied under defined conditions in which we could quantify changes in lymphatic contractile strength, lymph pump output, secondary valve function, and collecting vessel permeability. Results: Our results show that all these aspects of lymphatic vessel function are altered in deleterious ways in this model of hypercholesterolemia. Discussion: These findings extend previous in vivo observations suggesting significant dysfunction of lymphatic endothelial cells and smooth muscle cells from collecting vessels in association with a HFD on an ApoE-deficient background. An implication of our study is that collecting vessel dysfunction in this context may negatively impact the removal of cholesterol by the lymphatic system from the skin and the arterial wall and thereby exacerbate the progression and/or severity of atherosclerosis and associated inflammation.

Technique of Valve-Sparing Repair With Skeletonization of the Pulmonary Annulus for Tetralogy of Fallot

Pulmonary valve dysfunction after tetralogy of Fallot (TOF) repair increases morbidity and mortality in the long term. Several pulmonary valve‐sparing techniques have been introduced to prevent such adverse sequelae. In this article we describe our valve-sparing technique for TOF repair that primarily consists of skeletonization of the anterior part of the pulmonary annulus and gentle dilation to preserve the pulmonary valve and annulus function. Pulmonary valve dysfunction after tetralogy of Fallot (TOF) repair increases morbidity and mortality in the long term. Several pulmonary valve‐sparing techniques have been introduced to prevent such adverse sequelae. In this article we describe our valve-sparing technique for TOF repair that primarily consists of skeletonization of the anterior part of the pulmonary annulus and gentle dilation to preserve the pulmonary valve and annulus function.

Software-Driven Monitoring Approach Optimizes Well Integrity, Reduces Costs

_ This article, written by JPT Technology Editor Chris Carpenter, contains highlights of paper IPTC 22110, “Digitally Transformative U-WISE Software Technology,” by Nasser M. Al-Hajri, Syed Gilani, and Mohammed Saloojee, SPE, Saudi Aramco, et al. The paper has not been peer reviewed. Copyright 2022 International Petroleum Technology Conference. Reproduced by permission. _ In the complete paper, the authors introduce a model that provides risk-based financial optimization for surveillance programs. The model balances risk with financial investment to provide the asset owner with several optimization scenarios (at low risk and low investment) and ensures that surveys are not overdone. The example used to explain the model is one involving well-integrity surveillance. This example allows the oil operator to obtain a return on past investment made into collecting historical well-integrity data. Well-Integrity Surveys Several different kinds of well-integrity surveys are common in the industry, including the following: - Wellhead-integrity surveys use pressure to investigate the functionality and pressure-sealing integrity of the wellhead tree valves. The primary criterion of a successful wellhead-integrity test is that the valves are able to contain the well pressure without passing pressure outside the well to the surface flowline or the atmosphere. - Surface- and subsurface-safety-valve surveys are another critical test. The primary criterion of a successful surface- or subsurface-safety-valve test is that the valve functions properly by sealing the well pressure when activated. - Landing-base inspection is conducted by electronics that measure the metal loss of the landing base that seats the wellhead tree valves. The primary criterion of a successful landing-base inspection is for the landing base to have an acceptable metal loss without allowing fluid leaks from inside the well. - Annuli surveys are conducted using pressure to investigate the integrity of the cement-filled spaces between each downhole pipe. The primary criteria of a successful annuli survey are that no pressure is measured between the pipes and that no fluid is leaking through the cement from a downhole reservoir to surface. - Corrosion surveys measure the downhole pipes’ remaining metal loss. The primary criterion of a successful corrosion log is to record metal loss for downhole pipes lower than a minimum thickness determined by the well owner as being safe for operations. - Temperature surveys measure the downhole temperature profile and identify possible downhole pipe leaks. Typical downhole temperature profiles are geothermal trends that increase with depth. The temperature surveys not following a typical downhole temperature-gradient profile are flagged as anomalous and are investigated further. The primary criterion of a successful temperature survey is to obtain a downhole temperature recording that conforms to the base temperature-gradient profile without significant increase or decrease of temperature readings. In the complete paper, the authors provide a method of optimization for survey frequency. The temperature survey is used to explain the model work flow.

“An Open- Label Clinical Study to Compare the Combined Efficacy of Sahacharadi Taila Pana and Siravyadha with Exercise and Bandage in Varicose Veins”

Background: - Varicose veins are enlarged and twisted, veins at the skin surface of lower limb, due to poor functioning of valves in the deeper leg veins or venous insufficiency in the perforators, making blood back up in the legs, with the resulting pressure causing surface veins to enlarge. Bulging, cord-like, twisted, soft, swellings are seen on the legs, anywhere from the groin to the ankle, often associated with the complain of burning, throbbing, muscle cramping, swelling, or heavy feeling in the legs. Depending on the clinical presentation it is having a close proximity with Siragranthi mentioned in ayurvedic literature. Methodology : - Sixty patients diagnosed as varicose veins satisfying the inclusion criteria were selected. They were recruited into two Groups-Groups I and Group II-following randomised sampling with 30 patients in each group, by lottery method. The patients of group I received Sahacarāditaila pāna (drinking of milk processed with oil made up of Strobilanthes ciliates and other indigenous drugs) internally five ml with milk in empty stomach twice daily along with Siravyadha (puncture of vein), once in fifteen days, for two months (four sittings) along with cycling exercise. Group II patients were advised only to do exercise: "Cycling in air" morning and evening for 20 minutes and application of crepe bandage. Assessment was done before and after treatment for pain, night cramps, itching, ankle flare and venous clinical severity (VCSS) score. Result: - Pain, night cramps, and itching, reduced in both groups significantly with the p value &lt; 0.001. While comparing the result Group I and Group II, Group I showed much reduction in VCS score with the p value of &lt; 0.001. Conclusion: - Clinically both the group got reduction in symptoms of disease. Four Patients in Group I and three patients of group II got maximum improvement. Hence Sahacharadi tailapana and Siravyadha along with exercise &amp; bandage was more effective in reducing the sign and symptom of varicose veins as compared to simple exercise and pressure bandage.

Direct laser writing of hydrophobic and hydrophilic valves in the same material applied to centrifugal microfluidics.

In this study, we utilize nanosecond and femtosecond direct laser writing for the generation of hydrophobic and hydrophilic microfluidic valves on a centrifugal microfluidic disk made of polycarbonate, without the need for wet-chemistry. Application of a femtosecond (fs) laser at 800 nm resulted in an increased contact angle, from ∼80° to ∼160°, thereby inducing the formation of a hydrophobic surface. In contrast, employing a nanosecond (ns) laser at 248 nm led to the formation of superhydrophilic surfaces. Morphological studies identified the enhancement in the surface roughness for the hydrophobic surfaces and the creation of smooth patterns for the hydrophilic surfaces. Chemical modifications in the laser-ablated samples were confirmed via Fourier-transform infrared spectroscopy (FTIR) and X-ray photoelectron spectroscopy (XPS) analysis. These spectroscopic examinations revealed an increase of hydrophilic chemical groups on both surfaces, with a more pronounced increase on the nanosecond laser-modified surface. Furthermore, these surfaces were used as a case study for centrifugal microfluidic valves. These modified surfaces demonstrated peculiar pressure responses. Specifically, the hydrophobic valves necessitated a 29% increase in pressure for droplet passage through a microchannel. On the other hand, the superhydrophilic valves exhibited enhanced wettability, decreasing the pressure requirement for fluid flow through the modified area by 39%. However, similarly to the hydrophobic valves, the fluid exiting the hydrophilic valve area required an increased pressure. Overall, our study shows the potential for tailoring valve functionality in microfluidic systems through precise surface modifications using laser technology.

Real-time monitoring and actuation of a hybrid siphon valve for hematocrit-independent plasma separation from whole blood.

Centrifugal microfluidics have emerged as a pivotal area of research spanning multiple domains, including medicine and chemistry. Among passive valving strategies, siphon valves have gained prominence due to their inherent simplicity and self-reliance, eliminating the need for external equipment. However, achieving optimal valve performance mandates supplementary elements like surface adjustments or pneumatic pressure. These introduce intricacies such as time-dependent behavior and augmented spatial demands. This research introduces inventive design and manufacturing methodologies to amplify siphon valve functionality. Our proposed innovation situates the siphon microchannel on the external surface of the primary chamber, linked via an inlet. The crux of novelty lies in the adaptable material selection for the microchannel's upper or lower surfaces, allowing the integration of hydrophilic materials such as glass or super hydrophilic coverslips, ensuring a leakage-free operation. Our approach offers a streamlined concept and manufacturing process, ensures consistent time-independent functionality, and accommodates the integration of multiple siphon valves within a solitary chamber, tailored for specific applications. Experimental evaluations validate a robust alignment between acquired data and analytical outcomes based on a modified equation. A customized disc is engineered, featuring four siphon valves meticulously calibrated for hematocrit (HCT) levels spanning from 20% to 50% at 10% intervals. Harnessing these valves yields a substantial surge in plasma separation efficiency, scaling up to 75%. Notably, this performance eclipses traditional single-valve reliant microfluidic methodologies, achieving a purity level exceeding 99% in plasma separation. These findings underscore the auspicious practical applicability of our proposed technique in plasma separation, fostering heightened platelet concentration, and expediting blood sample analysis.

Mechanical Characterization of Porcine Tricuspid Valve Anterior Leaflets Over Time: Applications to Ex Vivo Studies

Abstract Mechanical characterization of the ex vivo tricuspid valve (TV) continues to provide key insights into native valve function and the development of valvular diseases. However, experimental methods to characterize TV biomechanical behavior ex vivo often fail to account for potential changes in the tissue’s mechanical responses that may occur during experiment preparation. Therefore, we assessed the mechanical responses of the anterior tricuspid leaflet (ATL) via biaxial mechanical testing over the course of 5 h to validate the accuracy of our fresh tissue experiments. We hypothesized that ATL mechanical responses would remain consistent for the proposed time scale. We found that ATL stiffness, represented by the upper tangent modulus (UTM), did not significantly change in either the radial or circumferential directions for the 5-h test period. Similarly, no significant change was observed in radial or circumferential strains corresponding to an estimated mean systolic stress value of 85 kPa. Overall mean UTM (±standard error of the mean (SEM)) showed that ATL samples were significantly stiffer in the circumferential direction (11.3 ± 0.98 MPa) compared to the radial direction (2.29 ± 0.20 MPa) across all time points. Thus, our results indicate that the outcomes of ex vivo tricuspid valve studies requiring sample preparation up to 5 h remain reliable.

Pre-Chamber spark ignition: a reliability analysis of pre-chamber valve functions

Pre-Chamber spark ignition: a reliability analysis of pre-chamber valve functions

Prosthetic heart valve thrombosis - a headache for the heart team: A case report

Introduction. Prosthetic valve thrombosis is usually a subacute or chronic condition, although it may also present with a fresh thrombus. It occurs in two forms: obstructive and non-obstructive thrombosis. Case Report. We present a case of a female patient who underwent mitral valve replacement with mechanical prosthesis due to severe mitral stenosis. The postoperative course was uneventful and the patient was discharged on vitamin K antagonist therapy with international normalized ratio target 3.0. Five months later, the patient was admitted with severe shortness of breath and signs of acute heart failure. International normalized ratio at that moment was 2.3. Transthoracic echocardiography indicated severely raised gradient across the prosthetic valve and mechanical valve malfunction was suspected. Cinefluoroscopy showed that one of the prosthetic valve leaflets was completely immobile. Transesophageal echocardiography definitely confirmed thrombosis of the prosthetic valve with large multiple thrombi that completely fixed one leaflet in closed position, and partially limited the motion amplitude of the other leaflet. There were thrombi floating between the left ventricle and left atrium. Thrombectomy of the prosthetic valve was performed, which was sufficient for the complete restoration of the mechanical valve function. The vitamin K antagonist dosage was carefully up-titrated in order to reach and maintain the target international normalized ratio of 3.0. Conclusion. Prosthetic valve thrombosis is a serious and life-threatening condition that requires urgent management. Coordination and cooperation of the whole heart team is necessary for optimal choice of treatment, which primarily includes surgery or fibrinolysis.

Study for the Comparison of CFD Analysis of Flow through Valves

Control valves are generally flow control equipment is utilized in a variety of sectors. The authors' modeling and simulation studies of various control valves are reviewed in this study. The findings of this research enable users to comprehend the flow pattern of a valve at various flow rates, as well as identify approaches for improving the valve's function. A gate valve was designed using Computational Fluid Dynamics (CFD) and CFD-powered software. The valve coefficient (Cv), often known as the flow coefficient, is a commonly used valve parameter. This paper presents the results of Flow Coefficient Analysis research.

Different Causes of Functional Tricuspid Valve Regurgitation Are Linked to Differences in Tricuspid Valve and Right-Sided Heart Geometry and Function: 3D Echocardiography Study.

Background and Objectives: The aim of this study was to clarify the tricuspid valve (TV) and right ventricular (RV) geometry and function characteristics using 3D echocardiography-based analysis and to identify echocardiographic predictors for severe tricuspid regurgitation (TR) in different etiologies of functional TR (fTR). Methods and Results: The prospective study included 128 patients (median age 64 years, 57% females): 109 patients with moderate or severe fTR (69-caused by dominant left-sided valvular pathology (LSVP), 40 due to precapillary pulmonary hypertension (PH)), and 19 healthy controls. The 2D and 3D-transthoracic echocardiography analysis included TV, right atrium, RV geometry, and functional parameters. All the RV geometry parameters as well as 3D TV parameters were increased in both fTR groups when compared to controls. Higher RV diameters, length, areas, volumes, and more impaired RV function were in PH group compared to LSVP group. PH was associated with larger leaflet tenting height, volume, and more increased indices of septal-lateral and major axis tricuspid annulus (TA) diameters. LVSP etiology was associated with higher anterior-posterior TA diameter and sphericity index. Univariate and multivariate logistic regression and ROC analyses revealed that different fTR etiologies were associated with various 2D and 3D echocardiographic parameters to predict severe TR: major axis TA diameter and TA perimeter, the leaflet tenting volume had the highest predictive value in PH group, septal-lateral systolic TA diameter-in LSVP group. The 3D TA analysis provided more reliable prediction for severe fTR. Conclusions: TV and RV geometry vary in different etiologies of functional TR. Precapillary PH is related to more severe RV remodeling and dysfunction and changes of TV geometry, when compared to LSVP group. The 3D echocardiography helps to determine echocardiographic predictors of severe TR in different fTR etiologies.

Echocardiography protocol: A tool for infrequently used parameters in mice.

Echocardiography is frequently used to evaluate cardiac function in rodent models of cardiovascular disease. Whereas methods to acquire the commonly used echocardiography parameters are well-described in published protocols or manuals, many important parameters are ill-defined and often open to subjective interpretation. Such lack of uniformity has engendered conflicting interpretations of the same parameters in published literature. In particular, parameters such as mitral regurgitation, mitral stenosis, pulmonary regurgitation, and aortic regurgitation that are required to define more esoteric etiologies in rarer mouse models often remain equivocal. The aim of this methods paper is to provide a practical guide to the acquisition and interpretation of infrequently used echocardiography parameters and set a framework for comprehensive analyses of right ventricle (RV), pulmonary artery (PA) pulmonary valve (PV), left atrium (LA), mitral valve (MV), and aortic valve (AoV) structure and function.

Ocupação Apical por Endomiocardiofibrose Associada a Trombo Diagnosticada com Ecocardiografia de Contraste e Resolvida com Tratamento Clínico

Endomyocardial fibrosis (EMF) is a neglected but prevalent disease in underdeveloped countries. Despite its frequency, it is still considered a rare disease. It is marked by the following findings: architectural distortion, ventricular filling changes, and segmental mobility changes affecting not only diastolic and systolic dynamics but also heart valve function. Apical thrombi can be formed in more advanced disease. In this case report, we revisit EMF and present the challenging case of a 52-year-old woman with New York Heart Association (NYHA) functional classification (FC) IV heart failure. Resting electrocardiography revealed sinus rhythm with left ventricular (LV) overload, high voltage vectors, rectified ST-segment depression, and a negative T-wave in the anterolateral region compatible with the strain pattern. The evaluation of echocardiographic images showed marked left atrial dilation, no ventricular dilatation, and hyper-refringent apical occupation within the LV suggestive of a large sessile thrombus superimposed on the endocardial fibrous layer. Although surgery is the most supported approach in the literature in such situations, this patient was treated with oral anticoagulants (OAC) for 1 month and 24 days. The patient progressed well with an improved NYHA FC. Endocavitary contrast echocardiography performed 2 months after OAC initiation showed regression of the apical thrombus image.

Analysis of flow torques during opening and closing of high-frequency rotary directional control valve

A 2D high-frequency rotary directional control valve with a spool having two degrees of freedom for axial linear motion and circumferential rotation is proposed in this paper. The axial linear motion decides the maximum orifice area, and the circumferential rotation lets the orifice area change continuously. One of the known elements impacting valve function is the flow force. This paper systematically analyzes the steady and transient flow torques subjected to the valve through theoretical analysis, AMESim-Fluent joint simulation and experimental tests. The results show that: under a single variable, the flow torques of the 2D high-frequency rotary directional control valve initially increase and then decrease like the sinusoid curve with the rotation of the spool and reach the maximum when the orifice opening is 1/2, and the flow torques are always in the direction of orifice closing and want to close the orifice. When the orifice area increases, the flow torques are the resistance, preventing the spool from opening; when the orifice area decreases, the flow torques are the power, pushing the spool to close. The steady flow torques are proportional to the pressure drop. The direction of the transient flow torque is independent of the relative position of the spool groove and sleeve window, which proportional to the square root of the pressure drop, orifice area and rotational speed. The flow torques are so important in the control of valve and can not be negligible.

Successful surgery of Ebstein’s anomaly of 11-year-old patient after having had two cardiac arrests

Ebstein’s anomaly is a rarely seen congenital heart disease with high morbidity and mortality rates. Impaired function of tricuspid valve and partially atrialized right ventricle are the main characteristics of the disease. Patients may have symptom-free survival for long terms whereas intra uterine death may also be encountered due to wide range of the symptoms. Regurgitation of the tricuspid valve and right-sided heart failure are the foremost symptoms. Surgery must be performed in symptomatic patients without delay. Carpentier’s approach to the surgical treatment of Ebstein’s anomaly is one of the methods that can be applicable. In this study it is reported that successful surgical treatment of 11-year-old child with Ebstein’s anomaly who had two cardiac arrests before operation, by using Carpentier’s technique.

326 STAGED ENDOVASCULAR TREATMENT FOR MULTIVALVULAR HEART DISEASE: A CASE REPORT

Abstract Background: Multiple valvular heart disease is a very prevalent condition and represents a challenge in terms of diagnosis and treatment. In patients undergoing cardiac surgery, multiple valvular lesions are often treated during the same procedure. In older high-risk patients, the treatment of choice for VHD is usually percutaneous: transcatheter aortic valve replacement (TAVR) has been widely developed in the past years and percutaneous interventions on other valvular lesions are rapidly evolving. In patients undergoing TAVR, concomitant severe tricuspid regurgitation (TR) is frequent and it's a marker of advanced disease. After TAVR, secondary TR can regress to a lower grade; persistent TR is associated with higher incidence of heart failure and mortality, so an additional intervention for TR is reasonable. The aim of this case report is to highlight the role of staged percutaneous treatment of multiple VHD as a new paradigm, with reassessment of other valvular lesion severity after the first endovascular valvular treatment Case description: We describe a case of successful staged percutaneous treatment for severe low flow – low gradient aortic stenosis in a 71 years old patient, with previous mitral valve replacement with mechanical valve and tricuspid annuloplasty, atrial fibrillation and COPD (STS score 9.5%). Four years after cardiac surgery she experienced worsening dyspnea and two hospitalizations for pulmonary edema; the echocardiography showed significant biventricular dysfunction, severe aortic stenosis (low-flow low-gradient, with contractile reserve at dobutamine stress echocardiography) and normal function of mitral prosthesis. The case was evaluated by a multidisciplinary ‘’Heart Team’’ and a decision was made to undergo TAVR and then reassess TR severity and patient symptoms. She underwent TAVR (Evolut Pro 26 mm direct implantation) using a ‘’less-invasive totally-endovascular’’ technique, without complications. Two month later the echocardiogram showed a little improvement in left ventricular systolic function and persistent severe tricuspid regurgitations; the patient was still symptomatic for leg swelling and fatigue. After a second evaluation from the ‘’Heart Team’’, she underwent successful transcatheter tricuspid valve-in-ring implantation (Edwards Sapien3 29) via right transgiugular approach, with no complications. 19 months after she was alive, with no more hospitalization, NYHA class II, on heart failure therapy; at an echocardiogram tricuspid regurgitation was mild-to-moderate. Discussion: Multivalular heart disease patients more often have several comorbidities, greater cardiac damage, that leads to higher incidence of heart failure and death than single VHD. In particular right ventricular dysfunction and tricuspid regurgitation, mostly secondary to pressure overload, are associated with adverse outcomes in severe aortic stenosis, especially in the ‘’low flow- low gradient’’ group. After treatment of a severe valvular disease, hemodynamic changes in pression and volume loads may improve the function of other valves, so previous valvulopaties can regress to a lower stage of severity, with a better prognosis and the possibility to avoid a second valvular treatment and all the procedural risks. Conclusion There is lack of data in the literature concerning the management of multiple VDH, which does not allow for evidence-based recommendations in current guidelines. Transcatherer interventions offer the option of a staged approach and a tailored treatment, after accurate evaluation by the Heart Team.