When Prosthetic Valves Compete for Space: A Case of Transcatheter Aortic Valve Embolization Due to Prosthetic Mitral Valve

Transcatheter aortic valve replacement (TAVR) is now the preferred choice of treatment for severe symptomatic aortic stenosis (AS) patients who are at intermediate to high risk for surgery. Rare complications like valve embolization have been described and we report a case with unique cause for such complication. A 79-year-old female presented with new onset dyspnea on exertion for evaluation and work up to the outside hospital and was found to have severe AS and referred to us for TAVR evaluation. She had a history of coronary artery bypass grafts surgery and bioprosthetic mitral valve replacement (MVR) 10 years ago. Preoperative transesophageal echocardiogram (TEE) revealed normally functioning bioprosthetic mitral valve and severe AS with peak/mean gradients of 67/44 mm Hg. She underwent transfemoral TAVR using a 26-mm Edwards Sapien S3 TAVR valve. During the slow deployment of the TAVR valve while rapid pacing, the valve appeared to move a little. Shortly after the removal of the delivery system out of the valve, the TAVR valve embolized to ascending aorta. It was carefully withdrawn into the aortic arch past the great vessels with an inflated balloon aortic valvuloplasty (BAV) catheter. Then, BAV was performed x 2 to plan for TAVR with a second valve, but the BAV balloon water-melon seeded repeatedly. We concluded that in this case, the rigid struts of bioprosthetic mitral valve encroaching on LVOT resulted in TAVR valve embolization and a decision was made to abort further attempts at TAVR valve implantation. This patient later under surgical aortic valve replacement (SAVR) and is clinically doing well at six months of clinical follow-up.