Table 58. Step 5: Type of severe multivalvular disease intervention^163–165.

Type	Considerations
Percutaneous balloon mitral valvuloplasty	Cases of severe MS with favorable anatomy and moderate aortic valvular heart disease
Surgical treatment (commissurotomy or valve replacement)	Conservative mitral valve surgery when stenosis is predominant Avoid aortic valve repair – frequent recurrence of valvular heart disease and symptoms, even with good immediate results Treatment of anatomically moderate valvular heart disease concomitant to intervention for severe valvular disease
Transcatheter treatment – valve-in-valve	Mitral and aortic bioprosthesis dysfunction, in symptomatic patients who have high surgical risk or are inoperable (following evaluation by the Heart Team)
Transcatheter treatment – TAVI and percutaneous mitral repair	Severe AS and severe primary MR, in patients with symptoms and/or prognostic factors, when there is a high surgical risk or contraindication to surgery (following evaluation by the Heart Team)

MR: mitral regurgitation; MS: mitral stenosis; TAVI: transcatheter aortic valve implantation.