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CASE DESCRIPTION The patient is an 80-year-old woman with a history of rheumatic heart disease requiring mitral valve replacement 34 years before presentation with a Bjork-Shiley valve. Seven years before presentation, she underwent tricuspid valve replacement with a no. 27 Medtronic Mosaic valve along with a maze procedure and permanent pacemaker implantation. Three years later, she underwent lumpectomy and radiation for breast cancer. Other history included multiple pulmonary emboli, thoracic outlet syndrome, and neuropathic lower extremity pain with right foot drop. The year before presentation, she began to experience lower extremity edema, ascites, and lack of appetite, and was found to have prosthetic tricuspid valve stenosis and insufficiency. On presentation, she exhibited New York Heart Association functional class IV symptoms, was wheelchair-bound, and unable to undergo exercise testing. Her echocardiogram showed an ejection fraction of 55%, 2þ tricuspid regurgitation, and severe stenosis with peak and mean gradients of 20 mm Hg and 16 mm Hg with reversal of hepatic systolic flow. Coronary angiography revealed no significant coronary artery disease. Pulmonary function testing demonstrated restrictive dysfunction (forced expiratory volume after 1 second of expiration [FEV1] 0.88 L, 39% of predicted) and severely reduced diffusing capacity of lung for carbon monoxide (DLCO 5.24 mL/min/mm Hg, 25% of predicted). Given her advanced age and comorbidities, she was judged to be at excessively high risk to undergo cardiac surgery at multiple

Transcatheter valve-in-valve tricuspid valve replacement via internal jugular and femoral approaches