A difficult case of retrieval of an aortic valve and balloon during a transcatheter aortic valve implantation

INTRODUCTIONTranscatheter aortic valve implantation (TAVI) represents an emerging therapy for valve replacement in patients not suitable for traditional open repair. As awareness of the procedure grows, case numbers are increasing worldwide. Though this procedure represents a less invasive approach to aortic valve replacement, it is not without complications.PRESENTATION OF CASEThis case presentation describes a serious, previously unreported, complication incurred in an 83-year-old male in whom TAVI was attempted. During deployment of the valve at the aortic annulus, both the valve and accompanying balloon embolised into the thoracic aorta and this was further complicated by migration of the balloon into the abdominal aorta and an aortic dissection. The false lumen of the dissection at the level of the infrarenal aorta was tacked to the aortic adventitial wall using interrupted sutures through a laparotomy. A completion angiogram demonstrated that a flow limited dissection did extend up to both common iliac arteries. This was managed with balloon-expandable covered stents deployed in both common iliac arteries with satisfactory outcome.DISCUSSIONThis case occurred as a combination of multiple factors that include lack of burst pacing and poor timing of the balloon inflation. The aortic balloon and the valve had to be removed urgently to avoid ventricular embolization of these structures that can result in a fatal situation.CONCLUSIONThis case presentation describes the management of these complications using a combined open and endovascular approach in a well-equipped hybrid operating theatre, resulting in the patient survival.