A 68-year-old woman who had symptomatic severe bicuspid aortic stenosis underwent transcatheter aortic valve (TAV) replacement with a 29-mm Edwards Lifesciences SAPIEN 3. The patient was on hemodialysis and diagnosed with multiple myeloma treated with immunomodulatory agent lenalidomide (estimated life longevity <7 years). 
110(5-35).mp4
2.mp4
3.mp4

At 19 months, transthoracic echocardiography (TTE) revealed aortic stenosis (mean aortic valve pressure gradient [AVPG]: 91mmHg). Considering the possible valve thrombosis, warfarin was initiated in addition to aspirin. However, TTE showed the valve dysfunction remained the same. Furthermore, computed tomography (CT) showed high-density areas of the valve leaflets suggesting severe calcification.
4.mp4
5.mp4

Therefore, our discipline team decided to perform TAV in TAV with a newer-generation 29-mm SAPIEN 3 Ultra Resilia. The procedure was successfully performed transfemorally under local anesthesia. TTE showed excellent results (mean AVPG: 6mmHg). However, 1 month later, TTE showed severe stenosis (mean AVPG: 61mmHg) and moderate transvalvular leakage. Also, CT showed hypo-attenuated leaflet thickening of the SAPIEN 3 Ultra Resilia. The valve function improved after re-initiating warfarin.
6.mp4
7.mp4
8.mp4

CT showed type-1 bicuspid aortic stenosis (annulus area: 662.6mm2). A 29-mm SAPIEN 3 was implanted with 2cc overfilling contrast. TAV in TAV was performed transfemorally under local anesthesia. A newer-generation 29-mm SAPIEN 3 Ultra Resilia with 4cc underfilling contrast was implanted in the deteriorated 29-mm SAPIEN 3 followed by post-dilation with a 25-mm balloon. 1 month later, TTE showed severe stenosis (mean AVPG: 61mmHg) and moderate transvalvular leakage. Also, CT showed hypo-attenuated leaflet thickening of the SAPIEN 3 Ultra Resilia. The valve function improved after re-initiating warfarin.
6.mp4
8.mp4
9.mp4

We reported a successful TAV in TAV case treated with a newer generation SAPIEN 3 Ultra Resilia in a deteriorated SAPIEN 3. This patient would be potentially at high risk of thrombosis due to chronic renal failure on hemodialysis and multiple myeloma treated with Lenalidomide, which was reported to promote thrombosis formation. These factors might be associated with early deterioration of the SAPIEN 3 and subsequent leaflet thrombosis of the SAPIEN 3 Ultra Resilia. We expect the anti-calcification effect of Resilia technology would contribute to acceptable valve function during follow-up.