81 year old female presents with worsening dyspnea on minimal exertion (NYHA class III) over the last few months. Her past medical history is significant for rheumatic heart disease with severe MR and MS s/p bioprosthetic MVR with 29 mm porcine valve (Biocor, St. Jude Medical) along with MAZE procedure in 2007. She also has persistent atrial fibrillation on warfarin. A recent TEE showed degeneration of the bioprosthesis with flail leaflet and severe MR with posteriorly directed MR jet. The transmitral gradient across the bioprosthesis was 8mmHg. There was diastolic flow predominance in the right and left upper pulmonary veins consistent with severe MR. The patient was evaluated by the Heart Team and was deemed high risk (STS
mortality 10.75%) for re-op surgical mitral valve replacement due to her advanced frailty and comorbidities. The patient is now planned for a mitral ViV TMVR with a 26 mm (+3 cc) Sapien-3
valve via transfemoral approach.