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Address for correspondence: Marek Kowalski MD, PhD, Department of Cardiology, Schüchtermann-Klinik, Ulmenallee 5-11, 49214 Bad Rothenfelde, Germany, phone: +49 542464130023, e-mail: MKowalski@schuechtermann-klinik.de Received: 16.10.2017, accepted: 25.11.2017. Transcatheter mitral valve edge-to-edge repair using the MitraClip system (Abbott Vascular, USA) and transcatheter aortic valve implantation (TAVI) are well established in high-risk or inoperable patients with severe mitral regurgitation and severe aortic stenosis [1, 2]. Furthermore, successful transcatheter tricuspid valve edge-to-edge repair using the MitraClip system has recently been described for high-risk patients with tricuspid regurgitation [3]. This valvular dysfunction is mainly caused by right ventricular dilatation driven by volume or pressure overload secondary to heart failure, mitral disease and/or aortic valvular disease [4]. Thus, most of these patients suffer from multivalvular disease. However, simultaneous transapical TAVI and transfemoral clipping of the mitral as well as tricuspid valve with MitraClip completed by occlusion of an atrial septal defect has not been described so far. We report hereby this firstin-human intervention in a high-risk patient. An 81-year-old male patient with a history of biventricular heart decompensation suffered from severe dyspnea on admission (New York Heart Association functional class III), lower leg edema, pleural effusions and stage III chronic kidney disease. Echocardiography revealed severe aortic stenosis (aortic valve area = 0.7 cm2) (Fig. 1). In addition, severe regurgitation of the tricuspid valve (effective regurgitation orifice area (EROA) = 0.88 cm2) and mitral valve (EROA = 0.44 cm2) with tethered leaflets was found (Fig. 2). Left and right ventricular function were reduced (ejection fraction of 50% and 35%, respectively). Elevated systolic pulmonary artery pressure could be documented (65 mm Hg). As a result of heart team discussion the patient was declared as surgically inoperable and qualified for transapical transcatheter aortic valve implantation – not suitable for a transvascular approach – followed by transfemoral edgeto-edge repair of mitral and tricuspid valves using the MitraClip system within one simultaneous procedure. All interventions were performed on July, 4th, 2017 under general anaesthesia using twoand three-dimensional transesophageal echocardiography (TEE) (iE 33, Philips Healthcare, Netherlands) and fluoroscopy guidance (Axiom Artis Zeefloor AXH 1604, Siemens, Germany). Unfractionated heparin was administered aiming at an activated clotting time (ACT) of 250–300 s throughout the procedure. For the transapical TAVI the left ventricular apex was surgically exposed (anterolateral minithoracotomy) and the apical suture was prepared. The apex was then punctured and a guidewire was placed in the left ventricular cavity and advanced through the aortic valve into the ascending aorta. Using the guidewire, a 5 Fr Impulse Femoral Right 4 Angiographic Catheter (Boston Scientific, USA) was introduced via the ventricular cavity in the descending aorta. Next a guide wire was placed (Amplatzer Super Stiff, Boston Scientific, USA) through the apex into the descending aorta. After that the 18 Fr sheath was introduced (Certitude, Edwards, USA) followed by the crimped valve (Sapien 3 TA 26 mm Aortic Bioprosthesis, Edwards, USA) and the device was positioned in the aortic valve annulus. The valve was implanted under aortic angiographic control and rapid pacing. The apex was closed after removing the introducer system. The procedure resulted in correct positioning of the aortic bioprosthesis with minimal aortic regurgitation (Fig. 3). Echocardiography showed a mean gradient of 5 mm Hg and an aortic valve area of 3.1 cm2. Then the mitral valve edge-to-edge repair using the MitraClip system was performed. After puncture of the right femoral vein and reaching the left atrium via transseptal puncture the steerable guiding catheter was placed into the left atrium and the clip delivery system (CDS) was introduced into the guiding catheter. The next step of the maneuver consisted of advancing the MitraClip device into the left atrium, opening both arms, navigation and advancing the system into the left ventricle. By retracting the MitraClip device both leaflets of the mitral valve were grasped and closed to coapt. Doing so, an effective reduction of mitral regurgitation could be achieved and the clip was deployed. The clip delivery system was evacuated. “All in” or “Rien ne va plus”? First simultaneous catheter-based trivalvular treatment combined with atrial septal closure in a human