Dynamic Transmitral Gradient From Eccentric Aortic Regurgitation Resolved by Valve-in-Valve TAVR
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Updated: Nov 7, 2026

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Published on: January 20, 2022
Ishita Ray1, Sami Shoura1, Ragavendar Saravanabavanandan1
1University of Illinois College of Medicine, Peoria, Illinois, USA.
Background:
Bioprosthetic aortic valve degeneration can present as isolated regurgitant failure, and an eccentric jet may raise the transmitral gradient, mimicking mitral stenosis.
Case Summary:
An 84-year-old man presented with acute heart failure 12 years after surgical aortic valve replacement. Echocardiography showed a degenerated Trifecta bioprosthesis with an immobile leaflet causing severe eccentric aortic regurgitation, whose jet impinged on the anterior mitral leaflet and produced severe functional mitral stenosis. Given high surgical risk, the heart team performed transfemoral valve-in-valve transcatheter aortic valve replacement.
Discussion:
Trifecta leaflet tear causes regurgitant rather than stenotic failure; an eccentric jet can raise the transmitral gradient independent of the Austin Flint murmur. Valve-in-valve transcatheter aortic valve replacement eliminated the regurgitation, improved leaflet mobility, and reduced the mean mitral gradient from 17 to 6 mm Hg, with complete symptom resolution.
Take-Home Message:
Eccentric aortic regurgitation can cause a reversible rise in transmitral gradient; treating it can resolve apparent mitral stenosis without mitral intervention.
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