82-year-old female presents with flash pulmonary edema and hypertensive emergency following a peripheral intervention. Past medical history is significant for TAVR in 2018, HTN, HLD, type II DM, CAD s/p RCA PCI, PAD s/p PTA, AF, DVT, and ESRD on HD. Transthoracic echocardiogram revealed LVEF of 63%, severe Sapien valvular aortic stenosis (PG/MG/EOA/EOAi/PV/DVI: 76/43/0.82/0.47/4.35/0.25), mild to moderate transvalvular AR and mild to moderate MR. Transesophageal echocardiogram showed abnormal percutaneous aortic prosthesis (PG/MG/EOA/EOAi/PV/DVI:49/26/0.68/0.41/3.5/0.24) with thickened and restricted prosthetic leaflet motion, mild to moderate aortic regurgitation consistent with a combination of structural valve degeneration and underlying patient prosthesis mismatch. CTA showed underexpanded 23 mm S3 in the mid frame. Her STS PROM risk for AVR was calculated at 18.8%. Heart Team evaluation found her to be extreme risk for SAVR. Patient preferred VIV Re TAVR. Now planned for trans-femoral TAVR via right percutaneous femoral arterial access using a 26 mm Evolut PRO+ in underexpanded 23mm SAPIEN 3 valve with Sentinel cerebral embolic protection device.

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