Www.auctoresonline.org
Transcatheter aortic valve dislocation into the left ventricle caused by the watermelon effect1Asst. Prof. Jo?ko Bulum, MD, PhD; 1prof. Strozzi Maja, MD, PhD; 1prof. Ani? Darko, MD, PhD; 2Tadej ?lahti?, MD, 2Luka Vitez, MD; 2prof. Matja? Bunc, MD, PhD 1Department of Cardiovascular Diseases, University Hospital Center Zagreb &University of Zagreb School of Medicine, Zagreb, Croatia2Clinical Department for Cardiology, University Medical Centre Ljubljana, Slovenia.Address for correspondence: Prof. Matja? Bunc, MD, PhDClinical Department for Cardiology, University Medical Centre Ljubljana, Slovenia.mbuncek@AbstractTranscatheter aortic valve implantation (TAVI) is a well-established method for treating severe aortic stenosis. Prosthetic valve dislocation immediately after deployment is a rare and feared complication. We present a case of a patient with severe, symptomatic aortic stenosis who was admitted for TAVI. During balloon inflation the valve (Edwards SAPIEN XT) dislocated into the left ventricle as a result of the watermelon effect caused by a narrow, severely calcified sino-tubular junction. A second valve of the same type and size was immediately implanted in a suboptimal position in order to reduce severe aortic regurgitation. This facilitated the use of veno-arterial extracorporeal membrane oxygenation support (V-A ECMO). The patient was thereafter stabilized and transferred for urgent surgery, where both prosthetic valves were removed. The aortic valve was replaced with an additional reconstruction of the ascending aorta.Keywords: aortic stenosis, TAVI, ventricular device dislocation, VA-ECMO, surgeryAbbreviations list: TAVI - transcatheter aortic valve implantation, TTE - transthoracic echocardiography, TEE - transesophageal echocardiography, AVA - aortic valve area,CTA - Computed tomography angiography, LVOT- left ventricular outflow tract, AR - aortic regurgitation, VA-ECMO - venoarterial extracorporeal membrane oxygenation supportIntroduction: Transcatheter aortic valve implantation (TAVI) is a well-established method for treating severe aortic stenosis in high, intermediate and even low surgical risk patients PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb3BtYTwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Qb3BtYTwvQXV0aG9yPjxZZWFyPjIwMTk8L1llYXI+PFJl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ADDIN EN.CITE.DATA [1, 2]. Prosthetic valve dislocation immediately after deployment is a rare and feared complication. It is usually the result of a prosthesis-annulus mismatch, too high or low implantation, ejection of the device by an effective ventricular contraction during deployment or lack of significant calcifications for prosthetic anchoring PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Vc3NpYTwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl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 EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5Vc3NpYTwvQXV0aG9yPjxZZWFyPjIwMTI8L1llYXI+PFJl
Y051bT4yMDU8L1JlY051bT48RGlzcGxheVRleHQ+WzMsIDRdPC9EaXNwbGF5VGV4dD48cmVjb3Jk
PjxyZWMtbnVtYmVyPjIwNTwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIg
ZGItaWQ9ImRmZXplYWQwYnhlcGY3ZWRkNXZ4ZHg5MWVlZDJlMmQ5cDAwdiIgdGltZXN0YW1wPSIx
NTk1NzU2MDY0Ij4yMDU8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5h
bCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPlVz
c2lhLCBHaWFuIFBhb2xvPC9hdXRob3I+PGF1dGhvcj5CYXJiYW50aSwgTWFyY288L2F1dGhvcj48
YXV0aG9yPlNhcmthciwgS3VuYWw8L2F1dGhvcj48YXV0aG9yPkFydXRhLCBQYXRyaXppYTwvYXV0
aG9yPjxhdXRob3I+U2NhcmFiZWxsaSwgTWFyaWxlbmE8L2F1dGhvcj48YXV0aG9yPkNhbW1hbGxl
cmksIFZhbGVyaWE8L2F1dGhvcj48YXV0aG9yPkltbcOoLCBTZWJhc3RpYW5vPC9hdXRob3I+PGF1
dGhvcj5QaXN0cml0dG8sIEFubmEgTWFyaWE8L2F1dGhvcj48YXV0aG9yPkd1bGlubywgU2ltb25h
PC9hdXRob3I+PGF1dGhvcj5NdWzDqCwgTWFzc2ltaWxpYW5vPC9hdXRob3I+PGF1dGhvcj5EZXN0
ZSwgV2FuZGE8L2F1dGhvcj48YXV0aG9yPkNhbm5hdGEsIFN0ZWZhbm88L2F1dGhvcj48YXV0aG9y
PlRhbWJ1cmlubywgQ29ycmFkbzwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48YXV0
aC1hZGRyZXNzPkRpdmlzaW9uIG9mIENhcmRpb2xvZ3ksIEZlcnJhcm90dG8gSG9zcGl0YWwsIFVu
aXZlcnNpdHkgb2YgQ2F0YW5pYSwgQ2F0YW5pYSwgSXRhbHkuIGdwdXNzaWFAaG90bWFpbC5jb208
L2F1dGgtYWRkcmVzcz48dGl0bGVzPjx0aXRsZT5UcmFuc2NhdGhldGVyIGFvcnRpYyBiaW9wcm9z
dGhlc2lzIGRpc2xvY2F0aW9uOiB0ZWNobmljYWwgYXNwZWN0cyBhbmQgbWlkdGVybSBmb2xsb3ct
dXA8L3RpdGxlPjxzZWNvbmRhcnktdGl0bGU+RXVyb0ludGVydmVudGlvbiA6IGpvdXJuYWwgb2Yg
RXVyb1BDUiBpbiBjb2xsYWJvcmF0aW9uIHdpdGggdGhlIFdvcmtpbmcgR3JvdXAgb24gSW50ZXJ2
ZW50aW9uYWwgQ2FyZGlvbG9neSBvZiB0aGUgRXVyb3BlYW4gU29jaWV0eSBvZiBDYXJkaW9sb2d5
PC9zZWNvbmRhcnktdGl0bGU+PGFsdC10aXRsZT5FdXJvSW50ZXJ2ZW50aW9uPC9hbHQtdGl0bGU+
PC90aXRsZXM+PGFsdC1wZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkV1cm9JbnRlcnZlbnRpb248L2Z1
bGwtdGl0bGU+PC9hbHQtcGVyaW9kaWNhbD48cGFnZXM+MTI4NS0xMjkyPC9wYWdlcz48dm9sdW1l
Pjc8L3ZvbHVtZT48bnVtYmVyPjExPC9udW1iZXI+PGtleXdvcmRzPjxrZXl3b3JkPlByb3N0aGVz
aXMgRmFpbHVyZTwva2V5d29yZD48L2tleXdvcmRzPjxkYXRlcz48eWVhcj4yMDEyPC95ZWFyPjxw
dWItZGF0ZXM+PGRhdGU+MjAxMi8wMy8vPC9kYXRlPjwvcHViLWRhdGVzPjwvZGF0ZXM+PGlzYm4+
MTc3NC0wMjRYPC9pc2JuPjxhY2Nlc3Npb24tbnVtPjIyNDMzMTkxPC9hY2Nlc3Npb24tbnVtPjx1
cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwOi8vZXVyb3BlcG1jLm9yZy9hYnN0cmFjdC9NRUQv
MjI0MzMxOTE8L3VybD48dXJsPmh0dHBzOi8vZG9pLm9yZy8xMC40MjQ0L0VJSlY3STExQTIwMzwv
dXJsPjwvcmVsYXRlZC11cmxzPjwvdXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+MTAuNDI0
NC9laWp2N2kxMWEyMDM8L2VsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjxyZW1vdGUtZGF0YWJhc2Ut
bmFtZT5QdWJNZWQ8L3JlbW90ZS1kYXRhYmFzZS1uYW1lPjxsYW5ndWFnZT5lbmc8L2xhbmd1YWdl
PjwvcmVjb3JkPjwvQ2l0ZT48Q2l0ZT48QXV0aG9yPkd1bDwvQXV0aG9yPjxZZWFyPjIwMTI8L1ll
YXI+PFJlY051bT4yMDc8L1JlY051bT48cmVjb3JkPjxyZWMtbnVtYmVyPjIwNzwvcmVjLW51bWJl
cj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIgZGItaWQ9ImRmZXplYWQwYnhlcGY3ZWRkNXZ4
ZHg5MWVlZDJlMmQ5cDAwdiIgdGltZXN0YW1wPSIxNTk1NzU2MTgzIj4yMDc8L2tleT48L2ZvcmVp
Z24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5hbCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNv
bnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkd1bCwgTWVobWV0PC9hdXRob3I+PGF1dGhvcj5F
cmthbmxpLCBLb3JoYW48L2F1dGhvcj48YXV0aG9yPkVyb2wsIE11c3RhZmEgS2VtYWw8L2F1dGhv
cj48YXV0aG9yPkJha2lyLCBJaHNhbjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48
dGl0bGVzPjx0aXRsZT5WZW50cmljdWxhciBlbWJvbGl6YXRpb24gb2YgRWR3YXJkcyBTQVBJRU4g
cHJvc3RoZXNpcyBmb2xsb3dpbmcgdHJhbnNjYXRoZXRlciBhb3J0aWMgdmFsdmUgaW1wbGFudGF0
aW9uPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkogSW52YXNpdmUgQ2FyZGlvbDwvc2Vjb25kYXJ5
LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxmdWxsLXRpdGxlPkogSW52YXNpdmUgQ2FyZGlv
bDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBhZ2VzPjUzNy01Mzg8L3BhZ2VzPjx2b2x1bWU+
MjQ8L3ZvbHVtZT48bnVtYmVyPjEwPC9udW1iZXI+PGRhdGVzPjx5ZWFyPjIwMTI8L3llYXI+PC9k
YXRlcz48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9DaXRlPjwvRW5kTm90ZT4A
ADDIN EN.CITE.DATA [3, 4]. Each prosthetic aortic valve has its own specific benefits and pitfalls. Even though there is still lack of data to claim superiority of one device over another, correct valve selection based on anatomical criteria is crucial for a safe and successful procedure ADDIN EN.CITE <EndNote><Cite><Author>Claessen</Author><Year>2021</Year><RecNum>249</RecNum><DisplayText>[5]</DisplayText><record><rec-number>249</rec-number><foreign-keys><key app="EN" db-id="dfezead0bxepf7edd5vxdx91eed2e2d9p00v" timestamp="1610378808">249</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Claessen, Bimmer E.</author><author>Tang, Gilbert H. L.</author><author>Kini, Annapoorna S.</author><author>Sharma, Samin K.</author></authors></contributors><titles><title>Considerations for Optimal Device Selection in Transcatheter Aortic Valve Replacement: A Review</title><secondary-title>JAMA Cardiol</secondary-title></titles><periodical><full-title>JAMA Cardiol</full-title></periodical><pages>102-112</pages><volume>6</volume><number><style face="normal" font="default" charset="238" size="100%">1</style></number><edition>2020/09/10</edition><dates><year>2021</year><pub-dates><date>Jan 1</date></pub-dates></dates><isbn>2380-6583</isbn><urls><related-urls><url>;[5]. In case of complications the valve most frequently dislocates upwards into the ascending aorta. Upwards snaring and positioning of a second valve is the usual strategy. The situation is much more demanding if the valve dislocates into the left ventricle. One of the possible bailout strategies includes a second valve implantation with simultanetous V-A ECMO support, followed by surgical extraction of the dislocated valve. ADDIN EN.CITE <EndNote><Cite><Author>Goslar</Author><Year>2016</Year><RecNum>210</RecNum><DisplayText>[6, 7]</DisplayText><record><rec-number>210</rec-number><foreign-keys><key app="EN" db-id="dfezead0bxepf7edd5vxdx91eed2e2d9p00v" timestamp="1595756361">210</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Goslar, Tomaz</author><author>Knafelj, Rihard</author><author>Radsel, Peter</author><author>Fister, Misa</author><author>Golicnik, Alenka</author><author>Steblovnik, Klemen</author><author>Gorjup, Vojka</author><author>Noc, Marko</author></authors></contributors><titles><title>Emergency percutaneous implantation of veno-arterial extracorporeal membrane oxygenation in the catheterisation laboratory</title><secondary-title>EuroIntervention</secondary-title></titles><periodical><full-title>EuroIntervention</full-title></periodical><pages>1465-1472</pages><volume>12</volume><number>12</number><dates><year>2016</year></dates><urls></urls></record></Cite><Cite><Author>Golicnik</Author><RecNum>211</RecNum><record><rec-number>211</rec-number><foreign-keys><key app="EN" db-id="dfezead0bxepf7edd5vxdx91eed2e2d9p00v" timestamp="1595756389">211</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Golicnik, Alenka</author><author>Bunc, Matjaz</author><author>Noc, Marko</author><author>Gorjup, Vojka</author></authors></contributors><titles><title>Successful use of percutaneous ECMO and intra-aortic balloon support for a rescue valve in valve TAVR procedure in a patient in cardiogenic shock</title></titles><dates></dates><urls></urls></record></Cite></EndNote>[6, 7] Here we present a case of balloon expandable valve dislocation into left ventricle. Successful treatment with second valve implantation and V-A ECMO bridge to surgery is presented and discussed. Case reportA 70-year old female with history of nicotine addiction, type 2 diabetes mellitus, dyslipidemia, long standing arterial hypertension, extreme obesity and rheumatoid arthritis was admitted to our cardiology department for heart failure symptoms. Chest radiography showed pulmonary congestion. Transthoracic echocardiography (TTE) showed a normal ejection fraction of 65%, severe aortic stenosis (aortic valve area 0.65 cm2, maximal velocity 5 m/s, mean gradient 58 mmHg) and mild mitral and tricuspid regurgitation. Pulmonary pressure was estimated at 35 mmHg. Coronarography showed normal coronary arteries and severe calcifications of the ascending aorta. The initial medical strategy was to treat heart failure symptoms with intravenous diuretic agents. After improvement we proceeded with preparations for TAVI. Computed tomography angiography (CTA) measurements revealed a severely calcified ascending aorta with an average annular diameter and perimeter of 21.4 mm and 67.2 mm respectively. Sinus of Valsava diameters were 26.1 mm, 27.4 mm and 25.8 mm. The sino-tubular junction had prominent ring calcifications and dimensions of 15.2 mm and 19.5 mm (Figure 1). Coronary ostia height was 11,3 mm for left and 23,2 mm for right coronary artery. She was evaluated by the local heart team. Due to her low operative risk (STS 3.3%) she was first a candidate for surgical treatment. However, having in mind the porcelain aorta, severe obesity and comorbidities, the heart team decided for TAVI. Due to a severely calcified aortic apparatus and small Sinus Valsalva diameter, we decided for an implantation of a balloon-expendable valve Edwards SAPIEN XT 23 mm (Edwards Lifesciences, Irvine, CA, USA) via transfemoral access. The other option at that time, the CoreValve (Medtronic, Dublin, Ireland) prosthesis, was not suitable due to its higher frame and risk of coronary arteries obstruction.The prosthetic aortic valve was advanced through right transfemoral approach. After pre-positioning, the valve was directly implanted under rapid ventricular pacing with 180 bpm. During final balloon expansion the valve dislocated towards the left ventricular outflow tract (LVOT) and was caught, with its top of the frame, on the calcified annulus (Video 1 and 2). With stable hemodynamic status the heart team discussed further options. Meanwhile, the valve further migrated and got transversely stuck in the LVOT (Video 3). Furthermore, the supporting guidewire was accidentally pulled out. Transesophageal echocardiography (TEE) revealed severe aortic regurgitation (AR) (Video 4). Patient developed cardiogenic shock with a drop of blood pressure to 60/25 mmHg. V-A ECMO support was inserted for hemodynamic stabilization on left site, contralateral to TAVI device sheet introducer. Simultaneously with V-A ECMO insertion we proceeded with an implantation of a second Edwards SAPIEN XT 23 mm (with 1 ml smaller balloon volume) valve to reduce severe AR. The expansion was intentionally slower. At the end of inflation the valve dislocated towards the LVOT (Video 5). Although the position was low it was functional and stable enough with support of the aortic annulus (Video 6). AR reduced to a mild degree with stable hemodynamic status on VA-ECMO. The patient was immediately transferred to a surgical operating room where both valves were removed (Figure 2) and a new, biological valve (Sorin Mitroflow 19, USA) was successfully implanted. The porcelain ascending aorta was reconstructed with a horse pericardial patch. The operation lasted 9 hours and was deemed successful. The patient recovered well without any neurologic deficit. At five year follow up the patient was still asymptomatic, without any signs of heart failure. Control CTA scan revealed normal dimensions of ascending aorta (Figure 3). TTE showed a normal left ventricle ejection fraction with a normal function of the biological prosthetic valve (aortic valve area 1.4 cm2, maximal velocity 3.16 m/s, mean gradient 26.8 mmHg,) (Figure 3). DiscussionThis case report shows a downward dislocation of a prosthetic aortic valve due to the watermelon effect. This means that the valve slipped in the LVOT most probably because of a narrow, severely calcified sino-tubular junction that squeezed the inflation balloon. (Video 5) In case of downward dislocation it is crucial that the valve remains on the supporting guidewire in order to maintain correct orientation PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HdWw8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxSZWNO
dW0+MjA3PC9SZWNOdW0+PERpc3BsYXlUZXh0PlsyLTQsIDhdPC9EaXNwbGF5VGV4dD48cmVjb3Jk
PjxyZWMtbnVtYmVyPjIwNzwvcmVjLW51bWJlcj48Zm9yZWlnbi1rZXlzPjxrZXkgYXBwPSJFTiIg
ZGItaWQ9ImRmZXplYWQwYnhlcGY3ZWRkNXZ4ZHg5MWVlZDJlMmQ5cDAwdiIgdGltZXN0YW1wPSIx
NTk1NzU2MTgzIj4yMDc8L2tleT48L2ZvcmVpZ24ta2V5cz48cmVmLXR5cGUgbmFtZT0iSm91cm5h
bCBBcnRpY2xlIj4xNzwvcmVmLXR5cGU+PGNvbnRyaWJ1dG9ycz48YXV0aG9ycz48YXV0aG9yPkd1
bCwgTWVobWV0PC9hdXRob3I+PGF1dGhvcj5FcmthbmxpLCBLb3JoYW48L2F1dGhvcj48YXV0aG9y
PkVyb2wsIE11c3RhZmEgS2VtYWw8L2F1dGhvcj48YXV0aG9yPkJha2lyLCBJaHNhbjwvYXV0aG9y
PjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0bGVzPjx0aXRsZT5WZW50cmljdWxhciBlbWJv
bGl6YXRpb24gb2YgRWR3YXJkcyBTQVBJRU4gcHJvc3RoZXNpcyBmb2xsb3dpbmcgdHJhbnNjYXRo
ZXRlciBhb3J0aWMgdmFsdmUgaW1wbGFudGF0aW9uPC90aXRsZT48c2Vjb25kYXJ5LXRpdGxlPkog
SW52YXNpdmUgQ2FyZGlvbDwvc2Vjb25kYXJ5LXRpdGxlPjwvdGl0bGVzPjxwZXJpb2RpY2FsPjxm
dWxsLXRpdGxlPkogSW52YXNpdmUgQ2FyZGlvbDwvZnVsbC10aXRsZT48L3BlcmlvZGljYWw+PHBh
Z2VzPjUzNy01Mzg8L3BhZ2VzPjx2b2x1bWU+MjQ8L3ZvbHVtZT48bnVtYmVyPjEwPC9udW1iZXI+
PGRhdGVzPjx5ZWFyPjIwMTI8L3llYXI+PC9kYXRlcz48dXJscz48L3VybHM+PC9yZWNvcmQ+PC9D
aXRlPjxDaXRlPjxBdXRob3I+VGFzPC9BdXRob3I+PFllYXI+MjAxNDwvWWVhcj48UmVjTnVtPjIw
ODwvUmVjTnVtPjxyZWNvcmQ+PHJlYy1udW1iZXI+MjA4PC9yZWMtbnVtYmVyPjxmb3JlaWduLWtl
eXM+PGtleSBhcHA9IkVOIiBkYi1pZD0iZGZlemVhZDBieGVwZjdlZGQ1dnhkeDkxZWVkMmUyZDlw
MDB2IiB0aW1lc3RhbXA9IjE1OTU3NTYyNjciPjIwODwva2V5PjwvZm9yZWlnbi1rZXlzPjxyZWYt
dHlwZSBuYW1lPSJKb3VybmFsIEFydGljbGUiPjE3PC9yZWYtdHlwZT48Y29udHJpYnV0b3JzPjxh
dXRob3JzPjxhdXRob3I+VGFzLCBNLiBIYWthbjwvYXV0aG9yPjxhdXRob3I+S296YSwgWWF2dXpl
cjwvYXV0aG9yPjxhdXRob3I+U2ltc2VrLCBaaXlhPC9hdXRob3I+PC9hdXRob3JzPjwvY29udHJp
YnV0b3JzPjx0aXRsZXM+PHRpdGxlPkluZnJhYW5udWxhciBkaXNsb2NhdGlvbiBhbmQgaXRzIHN1
Y2Nlc3NmdWwgbWFuYWdlbWVudDogQSByYXJlIGNvbXBsaWNhdGlvbiBmb2xsb3dpbmcgVEFWSTwv
dGl0bGU+PHNlY29uZGFyeS10aXRsZT5Kb3VybmFsIG9mIENhcmRpb2xvZ3kgQ2FzZXM8L3NlY29u
ZGFyeS10aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5Kb3VybmFsIG9mIENh
cmRpb2xvZ3kgQ2FzZXM8L2Z1bGwtdGl0bGU+PC9wZXJpb2RpY2FsPjxwYWdlcz4xNDgtMTUwPC9w
YWdlcz48dm9sdW1lPjk8L3ZvbHVtZT48bnVtYmVyPjQ8L251bWJlcj48a2V5d29yZHM+PGtleXdv
cmQ+QW9ydGljIHN0ZW5vc2lzPC9rZXl3b3JkPjxrZXl3b3JkPlRyYW5zY2F0aGV0ZXIgYW9ydGlj
IHZhbHZlIGltcGxhbnRhdGlvbjwva2V5d29yZD48a2V5d29yZD5EaXNsb2NhdGlvbjwva2V5d29y
ZD48L2tleXdvcmRzPjxkYXRlcz48eWVhcj4yMDE0PC95ZWFyPjxwdWItZGF0ZXM+PGRhdGU+MjAx
NC8wNC8wMS88L2RhdGU+PC9wdWItZGF0ZXM+PC9kYXRlcz48aXNibj4xODc4LTU0MDk8L2lzYm4+
PHVybHM+PHJlbGF0ZWQtdXJscz48dXJsPmh0dHA6Ly93d3cuc2NpZW5jZWRpcmVjdC5jb20vc2Np
ZW5jZS9hcnRpY2xlL3BpaS9TMTg3ODU0MDkxMzAwMTY1NTwvdXJsPjwvcmVsYXRlZC11cmxzPjwv
dXJscz48ZWxlY3Ryb25pYy1yZXNvdXJjZS1udW0+aHR0cHM6Ly9kb2kub3JnLzEwLjEwMTYvai5q
Y2Nhc2UuMjAxMy4xMi4wMDc8L2VsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjwvcmVjb3JkPjwvQ2l0
ZT48Q2l0ZT48QXV0aG9yPk1hY2s8L0F1dGhvcj48WWVhcj4yMDE5PC9ZZWFyPjxSZWNOdW0+MjA0
PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4yMDQ8L3JlYy1udW1iZXI+PGZvcmVpZ24ta2V5
cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJkZmV6ZWFkMGJ4ZXBmN2VkZDV2eGR4OTFlZWQyZTJkOXAw
MHYiIHRpbWVzdGFtcD0iMTU5NTc1NjAzMyI+MjA0PC9rZXk+PC9mb3JlaWduLWtleXM+PHJlZi10
eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10eXBlPjxjb250cmlidXRvcnM+PGF1
dGhvcnM+PGF1dGhvcj5NYWNrLCBNaWNoYWVsIEouPC9hdXRob3I+PGF1dGhvcj5MZW9uLCBNYXJ0
aW4gQi48L2F1dGhvcj48YXV0aG9yPlRob3VyYW5pLCBWaW5vZCBILjwvYXV0aG9yPjxhdXRob3I+
TWFra2FyLCBSYWo8L2F1dGhvcj48YXV0aG9yPktvZGFsaSwgU3VzaGVlbCBLLjwvYXV0aG9yPjxh
dXRob3I+UnVzc28sIE1hcms8L2F1dGhvcj48YXV0aG9yPkthcGFkaWEsIFNhbWlyIFIuPC9hdXRo
b3I+PGF1dGhvcj5NYWxhaXNyaWUsIFMuIENocmlzPC9hdXRob3I+PGF1dGhvcj5Db2hlbiwgRGF2
aWQgSi48L2F1dGhvcj48YXV0aG9yPlBpYmFyb3QsIFBoaWxpcHBlPC9hdXRob3I+PGF1dGhvcj5M
ZWlwc2ljLCBKb25hdGhvbjwvYXV0aG9yPjxhdXRob3I+SGFobiwgUmViZWNjYSBULjwvYXV0aG9y
PjxhdXRob3I+QmxhbmtlLCBQaGlsaXBwPC9hdXRob3I+PGF1dGhvcj5XaWxsaWFtcywgTWF0aGV3
IFIuPC9hdXRob3I+PGF1dGhvcj5NY0NhYmUsIEphbWVzIE0uPC9hdXRob3I+PGF1dGhvcj5Ccm93
biwgRGF2aWQgTC48L2F1dGhvcj48YXV0aG9yPkJhYmFsaWFyb3MsIFZhc2lsaXM8L2F1dGhvcj48
YXV0aG9yPkdvbGRtYW4sIFNjb3R0PC9hdXRob3I+PGF1dGhvcj5TemV0bywgV2lsc29uIFkuPC9h
dXRob3I+PGF1dGhvcj5HZW5lcmV1eCwgUGhpbGlwcGU8L2F1dGhvcj48YXV0aG9yPlBlcnNoYWQs
IEFzaGlzaDwvYXV0aG9yPjxhdXRob3I+UG9jb2NrLCBTdHVhcnQgSi48L2F1dGhvcj48YXV0aG9y
PkFsdSwgTWFyaWEgQy48L2F1dGhvcj48YXV0aG9yPldlYmIsIEpvaG4gRy48L2F1dGhvcj48YXV0
aG9yPlNtaXRoLCBDcmFpZyBSLjwvYXV0aG9yPjwvYXV0aG9ycz48L2NvbnRyaWJ1dG9ycz48dGl0
bGVzPjx0aXRsZT5UcmFuc2NhdGhldGVyIEFvcnRpYy1WYWx2ZSBSZXBsYWNlbWVudCB3aXRoIGEg
QmFsbG9vbi1FeHBhbmRhYmxlIFZhbHZlIGluIExvdy1SaXNrIFBhdGllbnRzPC90aXRsZT48c2Vj
b25kYXJ5LXRpdGxlPk5ldyBFbmdsYW5kIEpvdXJuYWwgb2YgTWVkaWNpbmU8L3NlY29uZGFyeS10
aXRsZT48L3RpdGxlcz48cGVyaW9kaWNhbD48ZnVsbC10aXRsZT5OZXcgRW5nbGFuZCBKb3VybmFs
IG9mIE1lZGljaW5lPC9mdWxsLXRpdGxlPjwvcGVyaW9kaWNhbD48cGFnZXM+MTY5NS0xNzA1PC9w
YWdlcz48dm9sdW1lPjM4MDwvdm9sdW1lPjxudW1iZXI+MTg8L251bWJlcj48ZGF0ZXM+PHllYXI+
MjAxOTwveWVhcj48L2RhdGVzPjxhY2Nlc3Npb24tbnVtPjMwODgzMDU4PC9hY2Nlc3Npb24tbnVt
Pjx1cmxzPjxyZWxhdGVkLXVybHM+PHVybD5odHRwczovL3d3dy5uZWptLm9yZy9kb2kvZnVsbC8x
MC4xMDU2L05FSk1vYTE4MTQwNTI8L3VybD48L3JlbGF0ZWQtdXJscz48L3VybHM+PGVsZWN0cm9u
aWMtcmVzb3VyY2UtbnVtPjEwLjEwNTYvTkVKTW9hMTgxNDA1MjwvZWxlY3Ryb25pYy1yZXNvdXJj
ZS1udW0+PC9yZWNvcmQ+PC9DaXRlPjxDaXRlPjxBdXRob3I+VXNzaWE8L0F1dGhvcj48WWVhcj4y
MDEyPC9ZZWFyPjxSZWNOdW0+MjA1PC9SZWNOdW0+PHJlY29yZD48cmVjLW51bWJlcj4yMDU8L3Jl
Yy1udW1iZXI+PGZvcmVpZ24ta2V5cz48a2V5IGFwcD0iRU4iIGRiLWlkPSJkZmV6ZWFkMGJ4ZXBm
N2VkZDV2eGR4OTFlZWQyZTJkOXAwMHYiIHRpbWVzdGFtcD0iMTU5NTc1NjA2NCI+MjA1PC9rZXk+
PC9mb3JlaWduLWtleXM+PHJlZi10eXBlIG5hbWU9IkpvdXJuYWwgQXJ0aWNsZSI+MTc8L3JlZi10
eXBlPjxjb250cmlidXRvcnM+PGF1dGhvcnM+PGF1dGhvcj5Vc3NpYSwgR2lhbiBQYW9sbzwvYXV0
aG9yPjxhdXRob3I+QmFyYmFudGksIE1hcmNvPC9hdXRob3I+PGF1dGhvcj5TYXJrYXIsIEt1bmFs
PC9hdXRob3I+PGF1dGhvcj5BcnV0YSwgUGF0cml6aWE8L2F1dGhvcj48YXV0aG9yPlNjYXJhYmVs
bGksIE1hcmlsZW5hPC9hdXRob3I+PGF1dGhvcj5DYW1tYWxsZXJpLCBWYWxlcmlhPC9hdXRob3I+
PGF1dGhvcj5JbW3DqCwgU2ViYXN0aWFubzwvYXV0aG9yPjxhdXRob3I+UGlzdHJpdHRvLCBBbm5h
IE1hcmlhPC9hdXRob3I+PGF1dGhvcj5HdWxpbm8sIFNpbW9uYTwvYXV0aG9yPjxhdXRob3I+TXVs
w6gsIE1hc3NpbWlsaWFubzwvYXV0aG9yPjxhdXRob3I+RGVzdGUsIFdhbmRhPC9hdXRob3I+PGF1
dGhvcj5DYW5uYXRhLCBTdGVmYW5vPC9hdXRob3I+PGF1dGhvcj5UYW1idXJpbm8sIENvcnJhZG88
L2F1dGhvcj48L2F1dGhvcnM+PC9jb250cmlidXRvcnM+PGF1dGgtYWRkcmVzcz5EaXZpc2lvbiBv
ZiBDYXJkaW9sb2d5LCBGZXJyYXJvdHRvIEhvc3BpdGFsLCBVbml2ZXJzaXR5IG9mIENhdGFuaWEs
IENhdGFuaWEsIEl0YWx5LiBncHVzc2lhQGhvdG1haWwuY29tPC9hdXRoLWFkZHJlc3M+PHRpdGxl
cz48dGl0bGU+VHJhbnNjYXRoZXRlciBhb3J0aWMgYmlvcHJvc3RoZXNpcyBkaXNsb2NhdGlvbjog
dGVjaG5pY2FsIGFzcGVjdHMgYW5kIG1pZHRlcm0gZm9sbG93LXVwPC90aXRsZT48c2Vjb25kYXJ5
LXRpdGxlPkV1cm9JbnRlcnZlbnRpb24gOiBqb3VybmFsIG9mIEV1cm9QQ1IgaW4gY29sbGFib3Jh
dGlvbiB3aXRoIHRoZSBXb3JraW5nIEdyb3VwIG9uIEludGVydmVudGlvbmFsIENhcmRpb2xvZ3kg
b2YgdGhlIEV1cm9wZWFuIFNvY2lldHkgb2YgQ2FyZGlvbG9neTwvc2Vjb25kYXJ5LXRpdGxlPjxh
bHQtdGl0bGU+RXVyb0ludGVydmVudGlvbjwvYWx0LXRpdGxlPjwvdGl0bGVzPjxhbHQtcGVyaW9k
aWNhbD48ZnVsbC10aXRsZT5FdXJvSW50ZXJ2ZW50aW9uPC9mdWxsLXRpdGxlPjwvYWx0LXBlcmlv
ZGljYWw+PHBhZ2VzPjEyODUtMTI5MjwvcGFnZXM+PHZvbHVtZT43PC92b2x1bWU+PG51bWJlcj4x
MTwvbnVtYmVyPjxrZXl3b3Jkcz48a2V5d29yZD5Qcm9zdGhlc2lzIEZhaWx1cmU8L2tleXdvcmQ+
PC9rZXl3b3Jkcz48ZGF0ZXM+PHllYXI+MjAxMjwveWVhcj48cHViLWRhdGVzPjxkYXRlPjIwMTIv
MDMvLzwvZGF0ZT48L3B1Yi1kYXRlcz48L2RhdGVzPjxpc2JuPjE3NzQtMDI0WDwvaXNibj48YWNj
ZXNzaW9uLW51bT4yMjQzMzE5MTwvYWNjZXNzaW9uLW51bT48dXJscz48cmVsYXRlZC11cmxzPjx1
cmw+aHR0cDovL2V1cm9wZXBtYy5vcmcvYWJzdHJhY3QvTUVELzIyNDMzMTkxPC91cmw+PHVybD5o
dHRwczovL2RvaS5vcmcvMTAuNDI0NC9FSUpWN0kxMUEyMDM8L3VybD48L3JlbGF0ZWQtdXJscz48
L3VybHM+PGVsZWN0cm9uaWMtcmVzb3VyY2UtbnVtPjEwLjQyNDQvZWlqdjdpMTFhMjAzPC9lbGVj
dHJvbmljLXJlc291cmNlLW51bT48cmVtb3RlLWRhdGFiYXNlLW5hbWU+UHViTWVkPC9yZW1vdGUt
ZGF0YWJhc2UtbmFtZT48bGFuZ3VhZ2U+ZW5nPC9sYW5ndWFnZT48L3JlY29yZD48L0NpdGU+PC9F
bmROb3RlPn==
ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5HdWw8L0F1dGhvcj48WWVhcj4yMDEyPC9ZZWFyPjxSZWNO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ADDIN EN.CITE.DATA [2-4, 8]. Prosthesis can then be successfully pulled out using a gooseneck snare and an inflated balloon, separately or in combination PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UYXM8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxSZWNO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ADDIN EN.CITE PEVuZE5vdGU+PENpdGU+PEF1dGhvcj5UYXM8L0F1dGhvcj48WWVhcj4yMDE0PC9ZZWFyPjxSZWNO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ADDIN EN.CITE.DATA [8, 9]. Tiroch K. et. al. ADDIN EN.CITE <EndNote><Cite><Author>Tiroch</Author><Year>2015</Year><RecNum>209</RecNum><DisplayText>[9]</DisplayText><record><rec-number>209</rec-number><foreign-keys><key app="EN" db-id="dfezead0bxepf7edd5vxdx91eed2e2d9p00v" timestamp="1595756323">209</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tiroch, Klaus</author><author>Schleiting, Heinrich</author><author>Karpettas, Nikos</author><author>Schmitz, Edgar</author><author>Vetter, Herbert O</author><author>Seyfarth, Melchior</author><author>Vorpahl, Marc</author><author>Thomas, M</author><author>Abdel‐Wahab, M</author><author>Sier, H</author></authors></contributors><titles><title>How should I treat dislocation of a TAVI SAPIEN prosthesis into the left ventricle?</title><secondary-title>EuroIntervention</secondary-title></titles><periodical><full-title>EuroIntervention</full-title></periodical><pages>1370-1372</pages><volume>10</volume><number>11</number><dates><year>2015</year></dates><urls></urls></record></Cite></EndNote>[9] reported a successful repositioning of a dislocated SAPIEN prosthesis with a partially inflated valvuloplasty balloon that was used for dragging an undersized prosthesis proximally in a sub-annular position under rapid ventricular pacing. Anchoring of the valve and prevention of distal migration was thereafter achieved with a second valve implantation. Surgical trans-apical approach with placement of a large sheath from the apex was proposed as an alternative strategy. The guidewires could then be snared and externalized via the sheath. Finally, the expanded valve would be crushed and withdrawn with forceps ADDIN EN.CITE <EndNote><Cite><Author>Tiroch</Author><Year>2015</Year><RecNum>209</RecNum><DisplayText>[9]</DisplayText><record><rec-number>209</rec-number><foreign-keys><key app="EN" db-id="dfezead0bxepf7edd5vxdx91eed2e2d9p00v" timestamp="1595756323">209</key></foreign-keys><ref-type name="Journal Article">17</ref-type><contributors><authors><author>Tiroch, Klaus</author><author>Schleiting, Heinrich</author><author>Karpettas, Nikos</author><author>Schmitz, Edgar</author><author>Vetter, Herbert O</author><author>Seyfarth, Melchior</author><author>Vorpahl, Marc</author><author>Thomas, M</author><author>Abdel‐Wahab, M</author><author>Sier, H</author></authors></contributors><titles><title>How should I treat dislocation of a TAVI SAPIEN prosthesis into the left ventricle?</title><secondary-title>EuroIntervention</secondary-title></titles><periodical><full-title>EuroIntervention</full-title></periodical><pages>1370-1372</pages><volume>10</volume><number>11</number><dates><year>2015</year></dates><urls></urls></record></Cite></EndNote>[9]. Unfortunately our procedure was further complicated with an accidental removal of the supporting wire. In combination with a rotated valve this prevented rewiring and correct valve orientation. After a successful implantation of a second valve with a smaller balloon volume, reduction of AR, V-A ECMO insertion and consequent patient hemodynamic stabilization, the only further possible solution was surgery. We may speculate that the use of a smaller volume balloon during expansion and post-dilatation with a lower position could prevent the watermelon effect and downward dislocation of the valve. Furthermore, balloon valvuloplasty with a 22 mm diameter balloon might improve our strategy in both, valve sizing and valve positioning. Acknowledgements: noneConflict of interes: Prof. Matja? Bunc, MD, PhD is in affiliation with Edwards Lifesciences (Sapien), Medtronic (Evolute), Mril (MyVal) and Abbott (Portico). He is advisory board member of Medtronic. Other authors have no disclosures with the industry. FiguresFigure 1 - Porcelain aorta and anatomy of severely calcified sino-tubular junction: A) Porcelain aorta on angiography. B), D) and C) CTA showing severe calcifications of aortic valve and ascending aorta. C) Narrow sino-tubular junction dimensions 15.2 mm x 19.5 mm.Figure 2: Both TAVI valves after surgical extraction.Figure 3 - follow-up TTE and CTA: A1) and A2) TTE 5 years after implantation of surgical aortic valve. B1) and B2) CTA 1 year after surgery showing proper anatomical position of biologic surgical valve.Video 1 - inflation: Inflation of the first Edwards SAPIEN XT valve during rapid pacing. Video 2 – final position of first valve: Low position of the Edwards SAPIEN XT valve.Video 3 – first dislocation: Dislocated Edwards SAPIEN XT valve in the LVOT.Video 4 –severe aortic regurgitation on TEE: Severe aortic regurgitation after migration of the first valve into LV. Video 5 - second valve implantation: Edwards SAPIEN XT valve implantation and watermelon effect. Video 6 – final position of valves and visible ECMO cannula: Final position of Edwards SAPIEN XT valves and visible V-A ECMO cannula.References ADDIN EN.REFLIST [1].Popma JJ, Deeb GM, Yakubov SJ, Mumtaz M, Gada H, O’Hair D, et al. Transcatheter Aortic-Valve Replacement with a Self-Expanding Valve in Low-Risk Patients. N Engl J Med. 2019;380(18):1706-15.[2].Mack MJ, Leon MB, Thourani VH, Makkar R, Kodali SK, Russo M, et al. Transcatheter Aortic-Valve Replacement with a Balloon-Expandable Valve in Low-Risk Patients. N Engl J Med. 2019;380(18):1695-705.[3].Ussia GP, Barbanti M, Sarkar K, Aruta P, Scarabelli M, Cammalleri V, et al. Transcatheter aortic bioprosthesis dislocation: technical aspects and midterm follow-up. EuroIntervention. 2012;7(11):1285-92.[4].Gul M, Erkanli K, Erol MK, Bakir I. Ventricular embolization of Edwards SAPIEN prosthesis following transcatheter aortic valve implantation. J Invasive Cardiol. 2012;24(10):537-8.[5].Claessen BE, Tang GHL, Kini AS, Sharma SK. Considerations for Optimal Device Selection in Transcatheter Aortic Valve Replacement: A Review. JAMA?Cardiol. 2021;6(1):102-112.[6].Goslar T, Knafelj R, Radsel P, Fister M, Golicnik A, Steblovnik K, et al. Emergency percutaneous implantation of veno-arterial extracorporeal membrane oxygenation in the catheterisation laboratory. EuroIntervention. 2016;12(12):1465-72.[7].Golicnik A, Bunc M, Noc M, Gorjup V. Successful use of percutaneous ECMO and intra-aortic balloon support for a rescue valve in valve TAVR procedure in a patient in cardiogenic shock. Trends in transplantation. 2019;12:1-3. Available from: doi: 10.15761/TiT.1000261[8].Tas MH, Koza Y, Simsek Z. Infraannular dislocation and its successful management: A rare complication following TAVI. J Cardiol?Cases. 2014;9(4):148-50.[9].Tiroch K, Schleiting H, Karpettas N, Schmitz E, Vetter HO, Seyfarth M, et al. How should I treat dislocation of a TAVI SAPIEN prosthesis into the left ventricle? EuroIntervention. 2015;10(11):1370-2. ................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related searches
- https www municipalonlinepayments
- bcps org jobs
- smartcu org sign on page
- aarp org membership card registration
- free org email accounts
- hackensackumc org pay bill
- get my transcripts org from college
- bcps org community volunteer info
- my access tgh org portal
- bcps org employee self service
- intranet florida hospital org employee
- typical finance org chart