Tricky Bioprosthetic Aortic Regurgitation

An 84-year-old male patient presented with the following medical history: ischemic cardiomyopathy with a left ventricular ejection fraction of 35% on recent echocardiogram, automatic implanted cardioverter-defibrillator, chronic kidney disease (stage II), World Health Organization category II pulmonary hypertension, and prior coronary artery bypass graft surgery, and bioprosthetic surgical aortic valve replacement (for aortic stenosis). In the past several weeks, the patient has had progressive shortness of breath, lower extremity edema, and decreased exercise tolerance. After seeing his primary cardiologist, he was sent to the emergency department where he was found to have elevated B-type natriuretic peptide levels, and creatinine of 4.0 mg/dL. After an initial trial of diuretics, dobutamine-assisted diuresis was initiated. Transthoracic echocardiography showed severe bioprosthetic aortic regurgitation and a left ventricular ejection fraction of 20%. The patient was evaluated by the cardiothoracic surgery team and deemed to be high risk for re-operative valve replacement with a Society of Thoracic Surgeons score of 12%.

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Based on the echocardiographic images, what should be the next best step in managing this patient?

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