2019 Scientific Sessions

Title: Ventricular embolization of transcatheter aortic valve treated percutaneously with second transcatheter valve Introduction: The use of balloon expandable transcatheter aortic valve replacement (TAVR) is now mainstream for severe symptomatic aortic stenosis and will likely be the dominant treatment option in the near future. Unique risks of this procedure have been described, including a small incidence of malposition and embolization. Most embolizations occur into the aorta when the procedure is transfemoral (TF) and is treated percutaneously with snaring or balloon trapping followed by implantation into the thoracic or rarely into the abdominal aorta. Left Ventricular embolization is less frequent and occurs more commonly with trans-apical (TA) implantation. This usually requires surgical removal. We report a case of transcatheter valve embolization (TVE) into the left ventricle treated in a unique and novel fashion by implantation of a second balloon expandable transcatheter valve. Clinical Case: A 79-year-old woman with history of severe chronic obstructive pulmonary disease, lung cancer (in remission), atrial fibrillation and hypertension was found to have severe aortic stenosis during investigation of NYHA class 3 dyspnea. Transthoracic Echocardiogram revealed a mean trans-aortic gradient of 80 mmHg and an aortic valve area of 0.5 cm2. Left Ventricular Ejection Fraction was 70%. Society of Thoracic Surgeons score was 6.0 (intermediate mortality risk) and TAVR was recommended. The patient was planned for TF-TAVR using the Edwards SAPIEN-3 valve (Edwards Lifesciences, Irvine, California). During the valve deployment, inadvertently the valve pusher was not pulled back sufficiently resulting in valve migration into the LVOT. This was immediately recognized, further valve expansion was terminated and an attempt made to pull the valve out of the LVOT with strong traction on the delivery system. However, the delivery balloon slipped out of the valve, and the latter remained in the LVOT. The Amplatz wire remained in position through the embolized valve. We expanded the embolized valve with a 20 mm True Dilatation Balloon Valvuloplasty Catheter (Bard-PV, Tempe AZ) deployed within and extending below the embolized valve. With the balloon inflated, the embolized valve was pulled higher into the LVOT and firmly embedded there, with the valve assuming the expected cylindrical shape. A second 23 mm Edwards SAPIENS S3 valve was then implanted in a slightly sub-annular position to anchor the embolized valve and simultaneously treat native aortic valve stenosis. TEE revealed mild paravalvular and no significant valvular regurgitation, normal trans-aortic gradient, mild interaction with the anterior mitral valve leaflet (mean diastolic mitral valve gradient 4.7mmHg) and mild mitral valve regurgitation. Discussion: Ventricular embolization of transcatheter valves is very rare and usually treated surgically. It is important to strictly follow the device IFU and pull back the valve pusher into ascending aorta sufficiently to prevent complication like this case. It is also very important to maintain the wire through the valve all the times, to exercise bailout options like deploying a second valve in a safe manner under close TEE surveillance for complications.