First Reported Case of Simultaneous Transjugular Tricuspid Valve-in-Ring and Pulmonary Valve-in-Valve Implantation.

BACKGROUND: Patients with repaired tetralogy of Fallot often require reinterventions for right-sided valve dysfunction. Surgical reoperations carry high morbidity, making transcatheter valve-in-valve and valve-in-ring procedures valuable alternatives. CASE SUMMARY: A 46-year-old man with repaired tetralogy of Fallot, prior tricuspid annuloplasty, pulmonary bioprosthesis, and transcatheter pacemaker presented with advanced right heart failure. Imaging showed massive right atrial enlargement, severe tricuspid stenosis/regurgitation, pulmonary dysfunction, and indwelling leads, precluding transfemoral access. Repeat surgery was prohibitive; thus, simultaneous transcatheter intervention was pursued. Via a transjugular approach, Edwards Sapien valves were implanted in both the tricuspid and pulmonary positions, with complete resolution of regurgitation. DISCUSSION: This case illustrates the feasibility of dual transjugular right-sided valve replacement in complex congenital heart disease. Meticulous imaging and planning allowed safe navigation of anatomical challenges. TAKE-HOME MESSAGE: A combined transjugular-approach valve-in-ring and valve-in-valve procedure can provide an effective alternative when surgery is prohibitive.