A 19-year-old Korean man without any medical history was admitted to the authors’ institution with complaints of high fever greater than 39.0°C, chill, and myalgia for one week. Transthoracic echocardiography at that time revealed severe tricuspid regurgitation, prolapse of the leaflets, and a mobile mass just distal to the tricuspid valve. Staphylococcus aureus was grown in blood cultures. His medical history prior to admission was only significant for repeated purulent infections in his right ingrown toenail for three months. Chest CT scans on admission demonstrated acute multifocal bronchopneumonia in both lungs. Transesophageal echocardiography showed prolapsed valve leaflets with coaptation failure and a mobile mass of 2.4 cm × 0.8 cm size between the tricuspid valve and the right ventricular outflow tract (Figure1A). On the admission day, the ingrown toenail was treated by partial avulsion medially. Staphylococcus aureus was also cultured from the toenail discharge. On the third hospital day, surgery was done under moderate hypothermic cardiopulmonary bypass. The medial papillary muscle supporting the anterior commissure of the tricuspid valve was completely disrupted from the ventricular septum, to which a 2.0-cm abscess lump covered with a thin, friable and smooth membrane was attached (Figure1B). The abscess was readily aspirated by a general sucker and the abscess base was cleaned with a curette. The disrupted papillary muscle and chordae and the inflammatory leaflet segment in the anterior commissure were excised (Figure2A). The commissural defect was augmented with an elliptical glutaraldehyde-treated autologous pericardial patch of 2.0 cm × 1.0 cm size using a continuous 5–0 polypropylene suture (Figure2B). The valve remained incompetent on saline test. A 28-mm MC³ annuloplasty ring (Edwards Lifesciences LLC; Irvine, CA, USA), which was chosen by the anterior leaflet area, was placed along the anatomical annulus, but the valve was still incompetent. After the ring was removed, a type of DeVega annuloplasty using a single row of 5–0 polypropylene sutures was performed. The annular plication suture was tightened until complete leaflet coaptation without regurgitation was achieved on saline test under occlusion of the main pulmonary artery (Figure2B)[2]. The complete leaflet coaptation occurred when the annular size was reduced to a No. 26 ring sizer (Model 1175 Sizers; Edwards Lifesciences LLC). A 26-mm MC³ ring was placed using two interrupted mattress 2–0 Dacron sutures near the atrioventricular node and two continuous 3–0 polypropylene sutures (Figure2; Figure3A). The anterior horn of the ring was sutured to the medial end of the attached patch instead of the anatomical annulus so that it could be placed along the margin of the functional valve opening. The valve showed a good coaptation on saline test (Figure3B). Early postoperative echocardiograms showed good valve competence. Follow-up echocardiography at 16 months postoperatively revealed trivial regurgitation, with a peak velocity of 1.3 m/sec and a mean transvalvular gradient of 3.0 mmHg. With peak treadmill exercise (stage IV, 13.3 METS by Bruce protocol), the transvalvular peak velocity and mean gradient were 2.4 m/sec and 8.0 mmHg, respectively.