Mechanical circulatory support is often challenging in patients with cardiogenic shock secondary to valvular heart disease because of challenging device placement, decreased efficacy, the need for a concomitant device for left ventricular unloading, or contraindications. Left atrial venoarterial-extracorporeal membranous oxygenation (LAVA-ECMO) is an emerging technique to achieve simultaneous ventricular unloading and circulatory support unaffected by valvular disease. The use of LAVA-ECMO for high-risk transcatheter valvular replacement has not been described. We describe the case of a patient with cardiogenic shock resulting from dual aortic and mitral bioprosthetic degeneration who was treated with LAVA-ECMO–supported dual-transcatheter aortic and mitral valve-in-valve replacement. Among many precautions worth mentioning, operators should be aware of the care and adjustments of the ECMO circuit required during transcatheter valvular replacement to achieve technical success without complications. The importance of a careful case planning in a multidisciplinary heart team meeting cannot be overemphasized. LAVA ECMO enables high-risk valvular replacement in patients in valvular cardiogenic shock.

Transcatheter aortic valve replacement (TAVR) has undergone rapid expansion, emerging as a viable therapeutic option for low-risk patients in lieu of surgical aortic valve replacement. This paper aims to provide a review of the scientific evidence concerning TAVR in low-risk patients, encompassing both observational and clinical trial data. Furthermore, a substantial proportion of low-risk patients possesses a bicuspid aortic valve, necessitating careful examination of the pertinent anatomic and clinical considerations to TAVR that is highlighted in this review. Additionally, the review expands upon some of the unique challenges associated with alternate access in low-risk patients evaluated for TAVR. Last, this review outlines the pivotal role of a multidisciplinary heart team approach in the execution of all TAVR procedures and the authors’ vision of ‘minimalist TAVR’ as a new era in low-risk TAVR.

A 78-year-old woman with bioprosthetic mitral valve degeneration at high risk for reoperation was referred for transcatheter mitral valve replacement. We describe the use of a preemptive alcohol septal ablation pre-procedurally to minimize the risk of acute left ventricular outflow tract obstruction given the anticipated need for a bioprosthetic valve fracture. (Level of Difficulty: Advanced.)