Cardiogenic shock following balloon post-dilatation in transcatheter aortic valve implantation: first case report of all three stuck leaflets

BACKGROUND: A stuck leaflet and frozen cusp are reported complications following transcatheter aortic valve implantation (TAVI). These complications are rare but can drastically change haemodynamics and be potentially life-threatening; thus, their awareness during TAVI is indispensable. Leaflet malfunction generally presents in one of the three leaflets of a prosthetic valve; however, we encountered a case where all three leaflets were simultaneously stuck. CASE SUMMARY: A 94-year-old woman was referred to our cardiology department with severe aortic stenosis. She underwent transfemoral TAVI. After a 20 mm balloon was inflated, a 23 mm Sapien 3 valve was deployed. Since the delivery balloon slipped into the ventricle, the valve top was not fully expanded. Post-dilatation using a 23 mm balloon was performed, which led to cardiogenic shock. Immediate cardiopulmonary resuscitation and venoarterial extracorporeal membrane oxygenation were provided. Since aortography and haemodynamics indicated severe aortic regurgitation and transoesophageal echocardiography depicted no leaflets inside the Sapien 3, we confirmed that all leaflets were stuck. The valve-in-valve procedure using the second 23 mm valve was successfully performed, and her haemodynamics dramatically improved. The patient was discharged 20 days later. DISCUSSION: Only a handful of cases have been reported on a stuck leaflet following post-dilatation. Root rupture is a major concern of the abrupt change after post-dilatation, but a stuck leaflet should also be considered even when the new-generation balloon-expandable valve, Sapien 3, is used. Here we report the first case in which all three leaflets were stuck.