Advanced rheumatic heart disease (RHD) with end stage sequelae is rarely seen in the United States. We report a complex case of a patient with advanced RHD complicated by Tricuspid stenosis, tricuspid regurgitation, mitral stenosis, and pulmonary hypertension in the setting of acute heart failure who undergoes urgent double valve replacement surgery. There are many notable complex interactions of the pathologies in patients with RHD who need to go on cardiac bypass.