An 85-year-old woman who had undergone transcatheter aortic valve (TAV) implantation with a 23-mm SAPIEN XT (Edwards Lifesciences, Irvine, CA, USA) 7 years earlier was admitted with congestive heart failure. Transthoracic echocardiography showed severe structural valve deterioration, with a mean aortic valve pressure gradient of 52 mmHg, valve area of 0.66 cm², and moderate transvalvular regurgitation. Transesophageal echocardiography and computed tomography revealed no vegetation, thrombus, or frame recoil. TAV-in-TAV implantation using a 23-mm SAPIEN 3 Ultra RESILIA (S3UR) was successfully performed under local anesthesia. Two-year follow-up echocardiography demonstrated satisfactory hemodynamic results, with a mean gradient of 20 mmHg, valve area of 1.36 cm², and mild regurgitation. Although TAV-in-TAV is an established strategy for structural valve deterioration, data on S3UR implantation within a SAPIEN XT—particularly in small annuli—are limited. This case demonstrates its feasibility, but further studies are needed.

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