During a recent TAVI case the valve embolized during deployment and became lodged in the proximal aortic arch in a “flipped” position, that is, 180 degrees off-axis in a direction opposite to the flow of blood. We present this case for further discussion and evaluation of learning points.
The patient is an 83-year-old male with severe aortic insufficiency and an aneurysmal ascending aorta. In an outpatient setting he was offered both open surgical aortic valve replacement as well as TAVI. He chose TAVI. Plans were made for implantation of a 29 mm Edwards Sapien 3 valve with a “nominal + 4 cc” deployment to achieve considerable oversizing. Once deployed, the valve’s position was visualized as 60-40, but repeat angiography 10 minutes later suggested several mm of ventricular migration. Given concern for potential ventricular embolization, the team elected to deploy a second (29 mm Sapien) valve in a slightly higher (aortic) position to stabilize the first valve. During deployment, the second valve embolized into the aorta. Attempts to reposition the valve into a more favorable, distal location failed and eventually resulted in loss of wire control through the valve. The valve became lodged in the proximal portion of the aortic arch in a position that would best be described as simply "upside-down." Multiple salvage options were in the process of being discussed by the team before proceeding further. However, at this time in the case, intraoperative transesophageal echocardiography indicated that the patient’s left ventricular ejection fraction had decreased to ~25%, having been normal at the beginning of the procedure. We present this case for continued discussion.
