CLINICAL IMAGES Avulsion of Aortic Leaflet During Transcatheter Aortic Valve Replacement GAUTAM R. PATANKAR, M.D., 1 PAUL A. GRAYBURN, M.D., 1 ROBERT F. HEBELER Jr., M.D., 2 ALBERT C. HENRY, M.D., 2 and ROBERT C. STOLER, M.D. 1 From the 1 Department of Cardiology, Baylor University Medical Center, Dallas, Texas; and 2 Department of Cardiothoracic Surgery, Baylor University Medical Center, Dallas, Texas (J Interven Cardiol 2016;29:549–551) An 82-year-old man with a past medical history of a 27 mm Mosaic porcine xenograft aortic valve placed 10 years ago for degenerative aortic stenosis was admitted for acute heart failure. Diagnostic work up revealed a degenerated surgical aortic valve (SAV) with severe regurgitation. Due to the patient’s prohibitive operative risk for open redo surgical aortic valve replacement (STS 10.4% þ 5% incrementals), the heart team referred the patient for transcatheter aortic valve replacement. The patient’s 27 mm Mosaic aortic valve has a true inner diameter—encompassing the leaflet tissue mounted within the stent—of 22 mm and therefore would accommodate a 26 mm CoreValve. During initial implantation, the CoreValve was positioned too high resulting in significant perivalvular leak (Fig. 1A and B). The valve was removed prior to full deployment; however, during removal, a leaflet of the patient’s SAV was avulsed. Transesophageal echocardiography showed severe aortic regurgitation (Fig. 2). The leaflet was retrieved along with the initial CoreValve (Fig. 3), and a second CoreValve was deployed deeper with satisfactory position and minimal perivalvular leak. Positioning was confirmed by echocardiography, root angiography, and hemody- namic assessment. Surprisingly, there was little hemodynamic change during the interval between the first and second CoreValve implants with LVEDP remaining approximately 20 mmHg (Fig. 4A–C). A possible explanation could be the patient’s chronic severe aortic regurgitation preconditioning the left ventricle for volume overload and higher diastolic pressure. Though there have been case reports of aortic valve leaflet avulsion as a consequence of routine coronary angiography 1 as well as with balloon valvuloplasty, 2 this is the first case of SAV leaflet avulsion during transaortic valve replacement. References 1. Shim C, Lee S, Wi J, et al. Aortic valve avulsion: Uncommon complication of coronary angiography. J Am Coll Cardiol 2012;60(2):e3. 2. Hamm C, Langes K, Vogel M, et al. Avulsion of a calcified leaflet as a complication of aortic valvuloplasty. Z Kardiol 1988; 70(10):674–677. Address for reprints: Dr. Gautam R. Patankar, MD, Department of Medical Education, Baylor University Medical Center, 3500 Gaston Avenue, Roberts 1st Floor C/o Shawn Guy-Pitts, Fellow- ship Coordinator, Dallas, TX 75246. Fax: 214-820-7533; e-mail: Gautam.Patankar@baylorhealth.edu © 2016, Wiley Periodicals, Inc. DOI: 10.1111/joic.12313 Vol. 29, No. 5, 2016 Journal of Interventional Cardiology 549