Background/Objectives: Alcohol septal ablation (ASA) is an established interventional therapy for patients with obstructive hypertrophic cardiomyopathy (OHCM) who remain symptomatic despite optimal medical treatment. Nevertheless, 10–20% of patients fail to achieve a satisfactory hemodynamic or clinical response, highlighting the need for improved patient selection. Given that mitral valve (MV) morphology plays a central role in left ventricular outflow tract (LVOT) obstruction, we aimed to evaluate the impact of MV anatomical parameters on ASA outcomes. Methods: We retrospectively analyzed 38 OHCM patients who underwent ASA and had complete echocardiographic data before and at 6-month follow-up. Patients were stratified into responders (n = 32, defined as >50% reduction in LVOT pressure gradient and/or residual LVOT gradient < 50 mmHg) and non-responders (n = 6, <50% reduction or persistent gradient ≥ 50 mmHg), consistent with criteria used in previous ASA outcome studies. MV parameters—including redundant anterior mitral leaflet (AML) length, posterior mitral leaflet (PML) projection, and anterior displacement of the coaptation point (AML/PML projection ratio)—were compared between groups. Results: Non-responders demonstrated significantly greater AML redundancy (13.16 ± 1.72 vs. 9.96 ± 1.99 mm, p < 0.001), larger PML projection (18.5 ± 3.78 vs. 13.65 ± 3.8 mm, p = 0.006), and lower AML/PML projection ratio (0.80 ± 0.15 vs. 1.34 ± 0.45, p = 0.007). These parameters were associated with reduced post-procedural LVOT gradient reduction in univariate logistic regression (p = 0.01, p = 0.027, p = 0.015, respectively). Multivariate modeling was not pursued due to collinearity among MV parameters and the limited number of non-responder events, which precluded robust adjustment. Conclusions: Mitral valve morphological features—particularly redundant AML, greater PML projection, and anterior displacement of the coaptation point—were associated with suboptimal ASA outcomes in univariate analysis. These data emphasize the need for comprehensive MV imaging in pre-procedural assessment. Integrating MV morphology into current selection algorithms may refine ASA patient selection and improve long-term success rates.

Background: The population of patients surviving previous multivalve surgery is expanding, and structural Heart Teams increasingly encounter complex, multivalvular disease requiring reintervention, for which redo surgery often carries prohibitive risk. Combined, single-session transcatheter treatment of two diseased valves is increasingly reported, but patient selection, procedural sequencing, prosthesis choice, and, in particular, pacing strategy and protection of pre-existing intracardiac hardware remain largely unstandardized. Case Presentation: We report a 73-year-old woman with a twenty-year history of rheumatic multivalvular heart disease, comprising mechanical mitral valve replacement, tricuspid annuloplasty and pacemaker implantation in 2006, redo bioprosthetic tricuspid valve replacement in 2019, and, in 2026, critical native aortic stenosis combined with severe bioprosthetic tricuspid stenosis. After multidisciplinary evaluation, the patient underwent single-stage transfemoral transcatheter aortic valve implantation (TAVI) followed immediately by tricuspid valve-in-valve implantation using a reversed balloon-expandable valve, with dedicated stiff guidewires positioned in each ventricle before device deployment and used as combined delivery-and-pacing platforms. Both procedures were successful, with no lead dysfunction, paravalvular leak, or other complications. Review: Using this case as a clinical anchor, we review contemporary evidence on simultaneous double-valve transcatheter intervention, addressing patient selection, the rationale for simultaneous versus staged treatment, valve sequencing, procedural planning, prosthesis choice, pacing strategies — including guidewire-based and leadless pacing — and management of permanent pacing leads, and propose a practical decision algorithm to guide Heart Team planning in similarly complex patients. Conclusions: Individualized, literature-informed Heart Team planning, including a dedicated biventricular guidewire strategy, can simplify combined transcatheter treatment of multivalvular disease in patients with pre-existing intracardiac hardware; this review provides a structured framework to support such planning as the evidence base for combined double-valve transcatheter intervention continues to grow.

Background: The population of patients surviving previous multivalve surgery is expanding, and structural Heart Teams increasingly encounter complex multivalvular disease requiring reintervention, for which redo surgery carries prohibitive risk. Patient selection, sequential procedural planning, prosthesis choice, and, in particular, pacing strategy and protection of pre-existing intracardiac hardware remain unstandardized. Case Presentation: We report a 73-year-old woman with a twenty-year history of rheumatic multivalvular heart disease, comprising mechanical mitral valve replacement, tricuspid annuloplasty and pacemaker implantation, redo bioprosthetic tricuspid valve replacement, and critical native aortic stenosis combined with severe bioprosthetic tricuspid regurgitation. After multidisciplinary Heart Team evaluation, the patient underwent successful single-session, sequential transfemoral transcatheter aortic valve implantation followed immediately by tricuspid valve-in-valve implantation using a reversed balloon-expandable valve and a dedicated biventricular guidewire pacing strategy. The sequential interventions achieved immediate hemodynamic success with no lead dysfunction, paravalvular leak, or other acute complications. Review: Using this case as a clinical anchor, we present a focused, case-based review of contemporary evidence on single-session double-valve transcatheter intervention. We address patient selection, procedural sequencing, imaging, prosthesis choice, and management of chronic transvenous pacing leads, providing a practical decision-making algorithm to guide Heart Teams in similarly complex scenarios. Conclusions: Individualized, multidisciplinary Heart Team planning, including a dedicated biventricular guidewire strategy, can simplify sequential transcatheter treatment of multivalvular disease in patients with pre-existing intracardiac hardware. This case-based review provides a pragmatic, hypothesis-generating framework to support clinical decision-making as the body of evidence for combined double-valve transcatheter interventions continues to evolve.