Difficult Cases and Complications from the Catheterization Laboratory: Case 1

  • Neil Ruparelia
  • Azeem Latib
  • Antonio ColomboEmail author


An 81-year-old lady presented to the Heart Team as an emergency with an episode of acute cardiac decompensation. Three years previously, she had undergone successful cardiac surgery with coronary artery bypass grafting (CABG) (saphenous vein graft – left obtuse marginal branch) with both mitral (25 mm Mosaic valve, Medtronic, Minnesota, USA) and aortic valve replacements (25 mm Epic valve, St. Jude, Minnesota, USA). She made an uneventful recovery from this surgery. Two years later, she presented as an emergency with bacterial endocarditis (Streptococcus sanguinis) affecting the aortic prosthesis that was successfully treated with prolonged ampicillin and gentamicin chemotherapy without the requirement for surgery. However, she was left with residual moderate aortic regurgitation (AR) in the absence of symptoms.


Aortic Regurgitation Transcatheter Aortic Valve Implantation Bioprosthetic Valve Minimal Lumen Diameter Embolic Protection Device 
These keywords were added by machine and not by the authors. This process is experimental and the keywords may be updated as the learning algorithm improves.

Supplementary material

Video 5.1

Severe aortic regurgitation. Five-chamber apical view, demonstrating severe aortic regurgitation (color Doppler flow) in the presence of preserved left ventricular systolic function (AVI 3007 kb)

Video 5.2

Mobile aortic valve mass. Short-axis view demonstrating appearance of mobile calcified mass on aortic valve leaflet, likely secondary to previously treated endocarditis (AVI 4414 kb)

Video 5.3

Severe aortic regurgitation. Aortography confirmed severe aortic regurgitation, secondary to aortic bioprosthesis dysfunction (AVI 13061 kb)

Video 5.4

Suboptimal positioning of TAVI prosthesis. After partial resheathing of Medtronic Evolut R, aortography demonstrated that the position was suboptimal (too low) and therefore the prosthesis was subsequently resheathed and the reposition to a higher, more ideal position (AVI 18950 kb)

Video 5.5

Final aortography. Final aortography demonstrated excellent position of the TAVI device with no evidence of aortic regurgitation (AVI 19718 kb)


  1. 1.
    Wiegerinck EM, Boerlage-van Dijk K, Koch KT, Yong ZY, Vis MM, Planken RN, Eberl S, de Mol BA, Piek JJ, Tijssen JG, Baan Jr J. Towards minimally invasiveness: transcatheter aortic valve implantation under local analgesia exclusively. Int J Cardiol. 2014;176:1050–2.CrossRefPubMedGoogle Scholar
  2. 2.
    Durand E, Borz B, Godin M, Tron C, Litzler PY, Bessou JP, Bejar K, Fraccaro C, Sanchez-Giron C, Dacher JN, Bauer F, Cribier A, Eltchaninoff H. Transfemoral aortic valve replacement with the Edwards SAPIEN and Edwards SAPIEN XT prosthesis using exclusively local anesthesia and fluoroscopic guidance: feasibility and 30-day outcomes. J Am Coll Cardiol Intv. 2012;5:461–7.CrossRefGoogle Scholar
  3. 3.
    Christiansen S, Schmid M, Autschbach R. Perioperative risk of redo aortic valve replacement. Ann Thorac Cardiovasc Surg Off J Assoc Thorac Cardiovasc Surg. 2009;15:105–10.Google Scholar
  4. 4.
    Vogt PR, Brunner-LaRocca H, Sidler P, Zund G, Truniger K, Lachat M, Turina J, Turina MI. Reoperative surgery for degenerated aortic bioprostheses: predictors for emergency surgery and reoperative mortality. Eur J Cardio Thorac Surg Off J Eur Assoc Cardiothorac Surg. 2000;17:134–9.CrossRefGoogle Scholar
  5. 5.
    Dvir D, Webb J, Brecker S, Bleiziffer S, Hildick-Smith D, Colombo A, Descoutures F, Hengstenberg C, Moat NE, Bekeredjian R, Napodano M, Testa L, Lefevre T, Guetta V, Nissen H, Hernandez JM, Roy D, Teles RC, Segev A, Dumonteil N, Fiorina C, Gotzmann M, Tchetche D, Abdel-Wahab M, De Marco F, Baumbach A, Laborde JC, Kornowski R. Transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: results from the global valve-in-valve registry. Circulation. 2012;126:2335–44.CrossRefPubMedGoogle Scholar
  6. 6.
    Azadani AN, Jaussaud N, Matthews PB, Ge L, Guy TS, Chuter TA, Tseng EE. Valve-in-valve implantation using a novel supravalvular transcatheter aortic valve: proof of concept. Ann Thorac Surg. 2009;88:1864–9.CrossRefPubMedGoogle Scholar
  7. 7.
    Soon JL, Ye J, Lichtenstein SV, Wood D, Webb JG, Cheung A. Transapical transcatheter aortic valve implantation in the presence of a mitral prosthesis. J Am Coll Cardiol. 2011;58:715–21.CrossRefPubMedGoogle Scholar
  8. 8.
    Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ, Investigators PT. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–98.CrossRefPubMedGoogle Scholar
  9. 9.
    Kahlert P, Knipp SC, Schlamann M, Thielmann M, Al-Rashid F, Weber M, Johansson U, Wendt D, Jakob HG, Forsting M, Sack S, Erbel R, Eggebrecht H. Silent and apparent cerebral ischemia after percutaneous transfemoral aortic valve implantation: a diffusion-weighted magnetic resonance imaging study. Circulation. 2010;121:870–8.CrossRefPubMedGoogle Scholar
  10. 10.
    Haussig, S, Mangner N, Dwyer MG, Lehmkuhl L, Lucke C, Woitek F, Holzhey DM, Mohr FW, Gutberlet M, Zivadinov R, Schuler G, Linke A. JAMA. 2016;316(6):592–601.Google Scholar
  11. 11.
    Buchanan GL, Chieffo A, Montorfano M, Maccagni D, Maisano F, Latib A, Covello RD, Grimaldi A, Alfieri O, Colombo A. A “modified crossover technique” for vascular access management in high-risk patients undergoing transfemoral transcatheter aortic valve implantation. Catheter Cardiovasc Interv Off J Soc Cardiac Angiography Interv. 2013;81:579–83.CrossRefGoogle Scholar

Copyright information

© Springer International Publishing Switzerland 2017

Authors and Affiliations

  • Neil Ruparelia
    • 1
    • 2
    • 3
  • Azeem Latib
    • 1
    • 2
  • Antonio Colombo
    • 2
    • 3
    Email author
  1. 1.Imperial CollegeLondonUK
  2. 2.San Raffaele Scientific InstituteMilanItaly
  3. 3.EMO-GV Centro Cuore ColumbusMilanItaly

Personalised recommendations