Transcatheter valve implantation for pure severe native aortic valve insufficiency (AI) without aortic stenosis has recently been described in a small series of inoperable or high-risk patients.1 We describe first transcatheter aortic valve replacement in a man using a novel caval-aortic approach in a high-risk patient with severe AI, who was deemed unsuitable for surgical aortic valve replacement. A 72-year-old man with severely dilated ischemic cardiomyopathy (ejection fraction, 20%) was admitted because of decompensated heart failure. A cardiac catheterization revealed nonobstructive coronary artery disease and severe (>4) AI. His Society of Thoracic Surgeons score was 12.4% mainly because of age, low ejection fraction, New York Heart Association class IV, peripheral arterial disease, severe chronic obstructive pulmonary disease, diabetes mellitus on insulin, and chronic kidney disease stage 3. Given his aforementioned comorbidities, he was deemed high-risk candidate for surgical valve replacement. Because of severe peripheral arterial disease and maximum subclavian diameter <5 cm, he was not amenable for conventional transfemoral or subclavian arterial approach. He was, therefore, planned for transcaval retrograde transcatheter aortic valve replacement with 31-mm self-expandable Medtronic CoreValve ReValving system (Figures 1 and 2). An informed consent was obtained and the procedure was performed under general anesthesia with unfractionated heparin as anticoagulant. The procedural steps are described in Figures 3 to 5. At 6-month follow-up, echocardiogram showed trace AI with good valve position. The patient remained free from rehospitalization and noted a significant improvement in functional capacity. Figure 1. Preprocedure computed tomographic planning. A , Aortic annulus of 29.3 mm (perimeter 9.2 cm). B , Sinotubular junction of 30.4 mm and aortic root of 40.5 mm. Figure 2. Preprocedural computed tomography to determine caval-aortic entry site. …