1 © Europa Digital & Publishing 2014. All rights reserved. HOW SHOULD I TREAT? EuroIntervention 2014;10-online publish-ahead-of-print September 2014 DOI: 10.4244/EIJY14M09_04 How should I treat dislocation of a TAVI SAPIEN prosthesis into the left ventricle? Klaus Tiroch 1 *, MD; Heinrich Schleiting 1 , MD; Nikos Karpettas 1 , MD, PhD; Edgar Schmitz 2 , MD; Herbert O. Vetter 2 , MD; Melchior Seyfarth 1 , MD; Marc Vorpahl 1 , MD 1. Department of Cardiology, HELIOS Klinikum Wuppertal, Witten/Herdecke University, Wuppertal, Germany; 2. Department of Cardiac Surgery, HELIOS Klinikum Wuppertal, Witten/Herdecke University, Wuppertal, Germany Invited experts: Martyn Thomas 1 , MD, FRCP; Mohamed Abdel-Wahab 2 , MD; Holger Sier 3 , MD; Gert Richardt 2 , MD 1. Cardiovascular Centre, St Thomas’ Hospital, London, United Kingdom; 2. Department of Cardiology, Heart Center, Segeberger Kliniken, Bad Segeberg, Germany; 3. Department of Cardiac Surgery, Heart Center, Segeberger Kliniken, Bad Segeberg, Germany The accompanying supplementary data are published online at: http://www.pcronline.com/eurointervention/ahead_of_print/201409-04 *Corresponding author: HELIOS Klinikum Wuppertal, Medizinische Klinik 3 - Kardiologie, Arrenberger Strasse 20, 42117 Wuppertal, Germany. E-mail: klaustiroch@hotmail.com PRESENTATION OF THE CASE A 73-year-old female patient was admitted in December 2013 with dyspnoea (NYHA Class IV) and marked peripheral oedema. Her medical history included three-vessel coronary disease with cor- onary bypass surgery in December 2009 (left internal mammary artery to the LAD and vein graft to the obtuse marginal branch), chronic obstructive pulmonary disease, anaemia associated with chronic heart failure and severe retroperitoneal fibrosis. Her cardio- vascular risk-factor profile included diabetes mellitus type 2, dys- lipidaemia, arterial hypertension and morbid obesity with a body mass index of 43. Echocardiography showed a high-grade calcified aortic valve stenosis (valve area 0.7 cm 2 ) with severe pulmonary hypertension. Coronary angiography showed stable coronary disease with patent grafts without the need for revascularisation. Due to the high perio- perative risk (EuroSCORE II of 20), the previous cardiac surgery and the patient being severely overweight, the Heart Team decision was in favour of a transfemoral TAVI under conscious sedation. The aortic annulus measurements revealed 20 mm on transoe- sophageal echocardiography and 21 mm on computer tomography, leading to the decision to use an Edwards SAPIEN XT 23 mm bal- loon-expandable valve (Edwards Lifesciences, Irvine, CA, USA). The intraprocedural balloon sizing based on the predilation sup- ported the choice of the 23 mm prosthesis (Moving image 1). After adequate prepositioning, the valve was implanted under rapid pac- ing with 200 beats per minute. The stored tension in the catheter system and a breathing manoeuvre of the patient led to the disloca- tion of the prosthesis into the left ventricle, still centred on the wire (Figure 1, Moving image 2, Moving image 3). Immediate haemo- dynamic parameters were stable and the Heart Team assessed the treatment options. CASE SUMMARY BACKGROUND: Despite the technical advancements of the transcatheter aortic valve implantation (TAVI) procedure, valve embolisation into the left ventricle remains a challeng- ing situation requiring expedited management through the Heart Team. INVESTIGATION: The advantages and pitfalls of an interven- tional transfemoral approach, a transapical extraction of the dislocated prosthesis or the conversion to open heart sur- gery have to be balanced depending on the overall situation and the specific characteristics of the patient. DIAGNOSIS: A transfemoral approach would be the first choice for most TAVI implanters. We discuss the different options and present an elegant solution solving this chal- lenging situation, leading to a good immediate and long- term outcome. MANAGEMENT: Attempts at pulling the prosthesis out of the ventricle using a balloon remained unsuccessful. After grasping of the prosthesis with a goose-neck snare, the valve was pulled into the annulus. A second SAPIEN XT pros- thesis was implanted and fixed the first prosthesis within the annulus. After post-dilatation, there was a good result without relevant gradient and minimal aortic regurgitation. KEYWORDS: aortic stenosis, bail-out, percutaneous valve, retrieval