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recently, understanding of the long-term consequences of untreated tricuspid pathology has improved. The 2014 American Heart Association/American College of Cardiology guidelines for the Management of Patients with Valvular Heart Disease list Class I evidence for TV repair/replacement in patients with severe tricuspid regurgitation (TR) or stenosis undergoing left-sided valve surgery [1]. However, bioprosthetic valves undergo degeneration over time. Re-operative surgical valve replacement is the standard of care but can be associated with significant operative mortality and morbidity, ranging from 13% to 37% [2]. Transcatheter tricuspid valve-in-valve (TVIV) implantation has emerged as an attractive alternative to surgical valve replacement in bioprosthetic valve dysfunction in patients at prohibitive surgical risk. We present a patient who successfully underwent transcatheter TVIV implantation as a salvage treatment option for bioprosthetic failure. Written consent was obtained. A 38-year-old male was admitted with symptoms of significant scrotal edema causing severe pain and impairing ambulation, shortness of breath, paroxysmal nocturnal dyspnea, orthopnea, and ascites. Past medical history included human immunodeficiency virus infection on highly active antiretroviral therapy, hypertension, pulmonary artery pseudoaneurysms, and substance abuse complicated by multimicrobial TV endocarditis. He had undergone two previous open TV surgeries (one for repair, one for replacement) with poor recovery following sternotomy, bioprosthetic valve endocarditis subsequently treated, and septic pulmonary emboli. He was diagnosed with severe bioprosthetic TV regurgitation and co-existing TV stenosis. A pre-operative transesophageal echocardiogram (TEE) revealed a TV mean pressure gradient of 17 mmHg and no evidence of vegetations on the valve. Due to his comorbidities and past surgical history, he was deemed a prohibitive-risk surgical candidate. After multidisciplinary discussion, a decision was made to perform a transfemoral transcatheter TVIV replacement. After placement of a pre-induction arterial line, general anesthesia (GA) was induced and a central venous catheter and TEE probe placed post-induction. Pre-procedural TEE revealed severe TR and stenosis, with mean pressure gradient of 14 mmHg. Femoral artery access was secured by the surgical team to facilitate emergent cardiopulmonary bypass, if needed. A Swan-Ganz catheter inserted from the femoral vein into the right ventricle (RV), was exchanged in a series of steps and a 29-mm Edwards Sapien 3 valve successfully deployed (Fig. 1) within the bioprosthetic TV. Hemodynamic stability improved Transcatheter tricuspid valve-in valve replacement-hope for the forgotten valve! Seema P. Deshpande, Susan Sankova, Nicolas Dorsey, Murtaza Y. Dawood, Kenichi Tanaka Division of Cardiothoracic Anesthesiology, Department of Anesthesiology, Division of Cardiac Surgery, Department of Surgery, University of Maryland School of Medicine, MD, Baltimore, USA Letter to the Editor