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Management of Stuck leaflet and Transcatheter vale embolization into the left ventricle
Takushi Kohmoto, Amish N. Raval, Giorgio Gimelli, Lucian Lozonschi.
University of Wisconsin, Madison, WI, USA.

OBJECTIVE: 1. Case History and Imaging Studies. 73 y lady with severe AS. She has COPD (FEV1 1.29), Pulmonary HTN (52 mmHg), frail, and morbidly obese (BMI 45), and was considered inoperable.
METHODS: 2. Relevant Imaging Studies. Her aortic valve annulus was 23 x 24 mm (annulus area was 450 mm2), and was considered as Transfemoral TAVR candidate with a 23 mm Sapien THV. Procedure was done on 5/14/2012.
RESULTS: 3. Procedures (5/14/2012). One of the leaflets of the implanted 23 mm Sapien was stuck and not opening. Multiple attempts to invert the leaflet using catheter (pigtail and AL2 catheters) were successful, and the leaflets started closing, but the valve dropped into the LVOT, below aortic annuls. Second Sapien valve (23 mm) was deployed as valve in valve position, but still it was too low. Then, the third Sapien valve (23 mm) was deployed in adequate position, and it was functioning normally. However, the previously deployed 2 valves dropped into the LV. The guide wire was kept in the 3 valves, especially to keep the 2 valves in the LV in forward orientation and the patient remained stable. Right small anterior thoracotomy was created and Fem-fem CPB was established. A stub wound was created at the LV apex after purse-string x2. The 2 valves were pinched by surgeon’s fingers, and manually extracted from the apex. The ventriculotomy was larger after removal, and was closed in two Teflon felt strip sandwich technique, similar to the LV aneurysm repair. She was discharged on POD 10.
CONCLUSIONS: 4. Teaching Points
1. It was crucial to keep the wire through the embolized valve, to keep forward flow orientation. 2. The embolized valve was successfully explanted via LV apex incision. 3. She later developed small VSD and small L to R shunt. 4. Even after 4 months, the third Sapien valve implanted was functioning normally (Mean gradient 9 mmHg). 5. Ultimately, she remained deconditioned and lack of motivation for rehab made her recovery challenging.

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