How should I treat a severely symptomatic, high-risk female patient with degenerated mitral (Carpentier-Edwards porcine) and aortic (Sorin Mitroflow) bioprostheses?

BACKGROUND: An 83-year-old woman was refferred to our dedicated out-patient clinic for evaluation fo the feasibility of trancather mital valve-in-valve implantation. She wa heavily symptomatic for dyspnoea, and was not a candidate for conventional surgeyr (logistic EuroScore 54.27%). The pre-porocedural evluation confirmed the presence of a severrly degenerated 27 mm Carpentier-Edwards porcine mitral bioprosthesis, and revealed the presence of a severely degenerated, malfunctioning 21 mm Sorin Mitroflow aortic bioprosthesis. INVESTIGATION: Clinical assessment, echocardiography cardiac catheterisation including coronary angiogram and aortography during balloon aortic valvulopathy (BAV), cardiac CT. DIAGNOSIS: Structural valve degeneration of the mitral bioprosthesis causing severe mitral stenosis and moderate to severe mitral regurgitation. Structural valve degeneration of the aortic bioprosthesis casuing severe aortic stenosis and severe aortic regurgitation. Tricuspid regurgitation. Pulmonary hypertension. Chronic renal failure. Patency of the coronary arteries during BAV. TREATMENT: Staged transapical mitral valve-in-valve implantation with a 26 mm Edwards SAPIEN valve and percutaneous aortic valve-in-valve implantation with a 23 mm Medtronic CoreValve.