A 73-year-old woman with a history of cerebral stroke with permanent left hemiplegia and rheumatic polymyalgia, presented to our Unit for exertional dyspnea. In 1995, the patient underwent surgical replacement with 23-mm stent-less Toronto SPV aortic root bioprosthesis (St. Jude Medical, St. Paul, MN) ( Fig. 1 A.1–2) for root dilatation and valve insufficiency. Echocardiographic assessment revealed prosthetic leaflets degeneration (valve area 0.7 cm 2 ; mean gradient 49 mmHg). Multi-slice computed tomography (MSCT) and tridimensional reconstruction (3mensio Structural Heart, Esaote, Genova Italy) demonstrated trans-catheter valve-in-valve (ViV) feasibility ( Fig. 1 B.1–2), even if a low height of the re-implanted unprotected left main (ULM) from the Dacron/annulus ( Fig. 1 B.3–4) was shown. A novel balloon-expandable (BE) trans-catheter heart valve (THV) (Myval 23 mm, Meril Life Sciences Pvt. Ltd., India) [ 1 ] was selected (frame height: 17.8 mm) for trans-femoral ViV. To prevent coronary obstruction, a 6F EBU 3.5 (Medtronic, CA, USA) guiding catheter was used to selectively engage the left coronary, a BMW guidewire (Abbott Vascular, Santa Clara, CA) was placed in the left anterior descending artery and a 4.0x28mm drug-eluting stent (Xience Sierra, Abbott Vascular, Santa Clara, CA) was positioned in the ULM before ViV. After THV deployment, DES was preventively implanted with a minimal protrusion in the aortic root lumen (“mini-chimney” technique) ( Fig. 1 C.1–4). No peri-procedural complications were recorded. At 6-month follow-up patient was asymptomatic and MSCT showed adequate THV position with DES patency ( Fig. 1 D.1–2). ViV in a stent-less full root bioprosthesis is a risk factor for early (ECO) and delayed coronary obstruction (DCO) [ 2 ]. Recent evidences demonstrate that ViV procedure with a BE-THV, compared to self-expanding ones, is associated with a lower DCO risk when coronary protection is managed by stent implantation compared to “wire-only” strategy [ 3 ]. This case highlights the performance of a novel BE-THV plus stent implantation to prevent ECO or DCO during ViV procedure involving a degenerated full root stent-less bioprosthesis with a low ULM height.