The authors describe a transcatheter mitral valve-in-valve-in-valve (VIVIV) for the correction of a degenerated transcatheter in a surgical bioprosthesis, a challenging interventional scenario that will be increasingly frequent in the near future. The key steps taken were as follows: preprocedural planning integrating data from transesophageal echocardiogram, cardiac computed tomography, and 3mensio reconstruction (Pie Medical Imaging); transfemoral transseptal VIVIV performed with EchoNavigator system (Philips) guidance; Sapien Ultra 3 26-mm valve (Edwards Lifesciences) delivered with buddy balloon maneuvers to uncage the valve from the atrial struts of the previously implanted valve; and atrial septal defect occlusion with the Amplatzer ASO 24 mm (Abbott Cardiovascular). The inability to advance the prosthesis into the ventricle, irreversible hemodynamic collapse, residual high transmitral mean gradient because of impingment of the 3 valves, residual paravalvular leaks, and left ventricular outflow tract obstruction. Mitral VIVIV procedures represent a viable option for patients with prohibitive surgical risk and a degenerated transcatheter in surgical bioprostheses. Success hinges on adequate preprocedural planning and a thorough understanding of bailout techniques to minimize failure and prevent major complications.

Background: Patients with atrial fibrillation (AF) have a five-fold increase in stroke events, and ∼90% of the thrombi develop in the left atrial appendage (LAA). Left atrial appendage occlusion (LAAO) has emerged as a safe and feasible alternative to oral anticoagulation (OAC) for stroke prevention in selected patients with non-valvular AF and contraindications to OAC. Atrial fibrillation is closely associated with mitral disease, and there is a growing interest in combined procedures. More than half of patients undergoing a mitral transcatheter edge-to-edge repair (M-TEER) suffer of AF and many have high or unacceptable bleeding risk. Case summary: We present a case of an 80-year-old woman suffering from paroxysmal AF, right carotid siphon aneurysm, and primary mitral regurgitation, with a high bleeding risk, who underwent a combined intervention of M-TEER and LAAO. Discussion: The combination of these two procedures is a logical step once the access to the left atrium is obtained with a transseptal puncture (TSP) and a transesophageal echocardiography (TEE) is in place to guide both procedures. The turning point in LAAO procedure is a correct TSP allowing coaxial alignment of the sheath with the LAA neck. Steerable delivery sheaths are promising dedicated tools, particularly in challenging anatomy or during combined procedures requiring different TSP positions.

Nonobstructive coronary artery disease is diagnostically challenging, especially in patients with recurrent chest pain and inconclusive imaging. Coronary functional abnormalities, such as vasospasm, microvascular dysfunction, and myocardial bridging, are key contributors to ischemia. A 57-year-old man with cardiovascular risk factors and a 10-year history of chest pain, empirically treated with vasodilators, presented with ST-segment elevation and ventricular fibrillation. Coronary angiography showed normal arteries. Invasive assessment with optical coherence tomography and coronary physiology revealed diffuse, nonobstructive lipid-rich atherosclerosis and a myocardial bridge in the mid left anterior descending artery. Ischemia was confirmed by resting full-cycle ratio. Coronary function testing showed microvascular dysfunction. Beta-blockers normalized indices, with symptom resolution at 6 months. This case illustrates the diagnostic value of invasive imaging and physiology in patients with myocardial infarction/myocardial ischemia with no obstructive coronary artery disease (INOCA/MINOCA). Invasive physiology and imaging are crucial for diagnosing ischemia mechanisms in nonobstructive coronary artery disease. Empirical therapy without functional assessment may delay effective, personalized treatment.

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Concomitant aortic stenosis and coronary artery disease in the elderly population is frequent and the proper therapeutic approach is a matter of debate. We present 2 challenging cases of patients affected by severe aortic stenosis and chronic total occlusion of the left main, demonstrating the safety and feasibility of transcatheter aortic valve replacement, performed both with balloon-expandable and self-expanding valves.