- Moderate aortic stenosis with mild regurgitation associated with regular follow-up care
- Permanent atrial fibrillation
- Previous cerebrovascular disease with no neurological deficit (2016)
- Sick sinus syndrome treated with VVI pacemaker implantation (Medtronic, 2022)
- Proton pump inhibitors, OD (before breakfast)
- Apixaban 5 mg, BD
- Bisoprolol 1.25 mg, OD
- Furosemide 25 mg, 2 tabs in the morning and 1 tab in the afternoon
- Allopurinol 300 mg, OD
- Canrenon 50 mg, OD
- Hemoglobin: 11,4 g/dl
- White blood cell count: 4,9 x 109/L
- Platelets: 124 x 109/L
- Creatinine: 1.16 mg/dl
- Alanine aminotransferase: 87 U/L
- Alkaline phosphatase: 75 U/L
- Total bilirubin: 1 µmol/L
- NT-ProBNP: 3456 ng/L
- Left ventricle: normal dimensions with global hypokinesia without segmental wall motion abnormalities resulting in a moderate reduction of the biplane ejection fraction (LVEF 35 %).
- Right ventricle: normal size, global and longitudinal systolic function (TAPSE 22 - S’ TDI 10 cm/sec).
- Severe left and right atrial volume dilation (LAVi 68 ml/m² - RAVi 73 ml/m²)
- Severe aortic stenosis with mild aortic regurgitation
- Anatomy: tricuspid valve
- Etiology: calcific degeneration
- Severity: G med 20 mmHg; AVA 0.78 cm²; AVAi 0.65 cm²/m²; DVI 0.22; SVi: 30 mL/m²
- Hemodynamic phenotype: classic low-flow low-gradient AS
- Cardiac damage staging: stage 3
- Severe tricuspid regurgitation (TR)
- Systolic PAP (sys-PAP) 55 mmHg
- Dilated IVC (22 mm), collapsible
Clinical presentation (December 2024)
An 82-year-old male (BMI of 23.7 kg/m2 - BSA 1.75) with arterial hypertension, type 2 diabetes mellitus, previous smoking habit, and occasional alcohol consumption, presented with increased shortness of breath, NYHA class III, and a history of frequent hospital admissions related to heart failure.
Past history
His past medical history included:
Medications
No known drug allergies were reported. Medical therapy at hospital admission included:
Physical examination
Vital signs were within normal range: blood pressure was 140/80 mmHg; heart rate was 86 beats/min; respiratory rate was 15 breaths/min; and oxygen saturation was 98 % on oxygen therapy via nasal cannula at 2 L/min.
The cardiac examination revealed an irregular cardiac activity, with a systolic murmur (4/6L) over all auscultation areas, radiating to the carotids. Signs of fluid overload were present: bilateral crackles on chest auscultation with bilateral lower limb edema and estimated jugular venous pressure.
No relevant neurological alterations.
Initial work-up
EKG: atrial fibrillation with paced ventricular rhythm at rate 50 bpm.
Lab tests:
Chest x-ray: mild bilateral pleural effusion with hilar-perihilar congestion; no evidence of parenchymal consolidation.
Transthoracic echocardiogram at hospital admission (Figure 1):
- No procedural complications
- Normal valve gradient with trivial perivalvular leak (Gmax/mean 10/6 mmHg, V max 1,6 cm/sec, DVI > 0.60)
- Residual severe tricuspid regurgitation with Sys-PAP 45 mmHg.
- The patient was discharged on day 3 after the procedure in NYHA class II. The first follow-up was planned after 45 days to reassess the TR severity.
Based on the clinical presentation and initial diagnostic work-up, the patient was diagnosed with acute decompensated heart failure due to multiple valvular heart diseases (VHD). Treatment with intravenous furosemide 120 mg was started1,2.
The diagnostic work-up of our patient continued with coronary angiography, which showed no significant coronary artery disease (Figure 2). The cardiac computed tomography was performed to complete the diagnostic work-up of severe AS (aortic valve calcium score » 2000 HU, Figure 2) and to proceed with Transcatheter Aortic Valve Implantation (TAVI) procedural planning3 (Figure 2).
Given the acute decompensated heart failure due to multiple severe VHD, the patient was discussed in the Heart Team weekly meeting. The final decision was to proceed first with TAVI and reassess the severity of tricuspid regurgitation at strict follow-up.
The patient was then discharged in stable NYHA class II. Dapagliflozin 10 mg OD was also started during the hospitalisation.
TAVI procedure (Feb. 2025) - Figure 3
Transfemoral TAVI with Navitor 29 mm bioprosthesis (Abbott Structural Heart, St Paul, MN, USA)
Clinical follow-up (April 2025)
The patient remained clinically stable, even though mild lower limb edema with elevated BNP levels in blood tests persisted. At follow-up TT echocardiogram, significant improvement of LVEF (35 % → 50 %) was observed. Normal valve function with stable trivial perivalvular leak (Grad. max/mean 10/4 mmHg) was described. Residual severe TR (VC 8 mm - TR EROA 41 mm2) with Sys-PAP 50 mmHg was reported.
- Chioncel O, Adamo M, Nikolaou M et al. Acute heart failure and valvular heart disease: A scientific statement of the Heart Failure Association, the Association for Acute CardioVascular Care and the European Association of Percutaneous Cardiovascular Interventions of the European Society of Cardiology. Eur J Heart Fail 2023;25:1025-1048.
- Vahanian A, Beyersdorf F, Praz F et al. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. Eur Heart J 2022;43:561-632.
- Dweck MR, Loganath K, Bing R et al. Multi-modality imaging in aortic stenosis: an EACVI clinical consensus document. Eur Heart J Cardiovasc Imaging 2023;24:1430-1443.
- Hahn RT, Badano L, Praz F et al. The Last Decade in Tricuspid Regurgitation: How Imaging Shaped a Field. JACC Cardiovasc Imaging 2025.
- Unger P, Galloo X, Pibarot P. Mixed valvular heart disease: diagnosis and management. Eur Heart J 2025;46:2261-2274.
- Unger P, Pibarot P, Tribouilloy C et al. Multiple and Mixed Valvular Heart Diseases. Circ Cardiovasc Imaging 2018;11:e007862.
- Paolisso P, Beles M, Belmonte M et al. Outcomes in patients with moderate and asymptomatic severe aortic stenosis followed up in heart valve clinics. Heart 2023;109:634-642.
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