Surgical Implantation of An Embolized CoreValve transcatheter Self-Expandable aortic bioprosthesis

Surgical Implantation of An Embolized CoreValve transcatheter Self-Expandable aortic bioprosthesis | Research Square window.SnipcartSettings = { analytics: { enabled: false } }; (function() { var accessVector = localStorage.getItem('access_vector') || ''; window.dataLayer = window.dataLayer || []; if (accessVector) { window.dataLayer.push({ user: { profile: { profileInfo: { snid: accessVector } } } }); } })(); (function(w,d,s,l,i){w[l]=w[l]||[];w[l].push({'gtm.start':new Date().getTime(),event:'gtm.js'});var f=d.getElementsByTagName(s)[0],j=d.createElement(s),dl=l!='dataLayer'?'&l='+l:'';j.async=true;j.src='https://www.googletagmanager.com/gtm.js?id='+i+dl;f.parentNode.insertBefore(j,f);})(window,document,'script','dataLayer','GTM-K279D39R'); Browse Preprints In Review Journals COVID-19 Preprints AJE Video Bytes Research Tools Research Promotion AJE Professional Editing AJE Rubriq About Preprint Platform In Review Editorial Policies Our Team Advisory Board Help Center Sign In Submit a Preprint Cite Share Download PDF Case Report Surgical Implantation of An Embolized CoreValve transcatheter Self-Expandable aortic bioprosthesis Seyed Mohammad Forouzannia, Marziyeh Pakbaz, Ali Mohammad Haji zeinali, and 2 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-4601977/v1 This work is licensed under a CC BY 4.0 License Status: Posted Version 1 posted You are reading this latest preprint version Abstract We report on a case of failed Transcatheter aortic valve replacement (TAVR) in a 78-year-old male, complicated by the dislodgment of a CoreValve into the distal ascending aorta after it was successfully implanted. The case was managed surgically by retrieving and re-implanting the dislodged valve as a bailout strategy. CoreValve Transcatheter aortic valve replacement Figures Figure 1 Figure 2 Figure 3 INTRODUCTION TAVR, in the modern era of valvular disease management, is considered an attractive alternative to surgery in higher-risk patients with symptomatic aortic stenosis. 1 TAVR is associated with the potential for serious complications. Valve embolization (VE) is defined as the valve prosthesis movement during or after deployment such that it loses contact with the aortic annulus. 2 VE occurs in approximately 0.2% of cases using self-expanding Medtronic CoreValve. 1 VE of a partially or entirely deployed CoreValve prosthesis can be managed interventionally in most cases. 3 Other cases require Aortic Valve (AV) replacement using the conventional surgical approach. CASE REPORT A 78-year-old male was referred to our center with recently diagnosed symptomatic severe aortic stenosis after being evaluated for progressive exertional dyspnea. Transthoracic echocardiography revealed a mean trans-aortic pressure gradient of 56mmHg and AV area of 0.6 cm2 with an ejection fraction of 55%. Coronary angiography revealed minimal non-obstructive coronary artery disease. The patient refused surgical aortic valve replacement (SAVR) despite a low-risk conventional surgery (Society of Thoracic Surgeons Score, 1%); hence, he was scheduled for transfemoral TAVR. Based on the integrated measurements obtained by multi-slice spiral CT angiography, a 34 mm valve prosthesis was suggested; however, regarding the heavy calcification of the AV with a calcium score of 6367, the Heart Team decided to proceed with a 29mm valve prosthesis, to avoid the risk of annular rupture. Transfemoral TAVR was performed with the aid of transesophageal echocardiography (TEE) (Supplementary Video 1). under general anesthesia, followed by a surgical exploration of the right common femoral artery. After loading the delivery system over a J-tipped stiff guidewire and certainty about good planar angle positioning in a 5mm depth under the annulus (Fig. 1 A, Supplementary Video 2), the prosthesis was deployed under rapid pacing. With close monitoring by fluoroscopy, the inflow part of the self-expanding prosthesis was first deployed properly (Fig. 1 B, Supplementary Video 2), followed by expeditious deployment of the outflow part and after the team was satisfied with the valve position, the system was released (Fig. 1 C, Supplementary Video 2). As the delivery system was withdrawn following full deployment, the valve suddenly migrated into the ascending aorta (Fig. 1 D, Supplementary Video 3). TEE showed the migrated valve with its inflow part positioned just beyond the sinotubular junction (Fig. 1 E, Supplementary Video 4). After completely removing the guidewire and pigtail catheter, the final fluoroscopy and TEE images showed the free-floating, fully-expanded CoreValve prosthesis within the distal ascending aorta (Fig. 1 F, Supplementary Video 5 and 6). The patient’s hemodynamics deteriorated suddenly. Hence, the Heart team proceeded with emergent bailout surgery (Fig. 2 ). Median sternotomy was performed, and the “bouncing” valve prosthesis was palpable high in the ascending aorta, with its upper pole near the origin of the innominate artery and the lower pole at a lower point in the distal of the ascending aorta. Under cardiopulmonary bypass, a longitudinal aortotomy was performed (Fig. 2 A). The stent valve was then retrieved without damage (Fig. 2 B, Supplementary Video 7) and immediately submerged in ice-cold sterile saline. Cardiac arrest was achieved following direct intra-coronary administration of cardioplegia. The native AV was explored and showed a heavily calcified tricuspid valve with a bulkier calcification on the right coronary cusp, which seemed to be incompressible and resulted in complete immobility of this cusp (Fig. 2 C). The leaflets of the native AV were totally excised, and the annulus debrided of calcification. The heavy calcification of AV extended to the base of the anterior mitral valve leaflet, so decalcification of this valve was also performed. At the next step, the retrieved valve prosthesis was prepared for reimplantation (Fig. 3 ). Akin to the routine pre-TAVR rinsing and loading procedure, we immersed the prosthesis in a sterile bowl of ice-saline to shrink the nitinol stent frame, especially at the annulus level (Fig. 3 A). Multiple interrupted mattress sutures encircling the prosthesis annulus were placed (Fig. 3 B). After manual crimping of the lower pole of the stent, the prosthesis was lowered to the native aortic annulus and seated properly, and the sutures were tied and secured (Fig. 3 C). Finally, the coaptation of the leaflets was checked, and the aortotomy was closed. The patient was easily weaned off from cardiopulmonary bypass, and the surgery was completed after post-pump TEE, which confirmed the successful result of surgery with normal biventricular function, acceptable leaflet motion, and hemodynamic study (mean trans-aortic pressure gradient of 12mmHg) and a no para or transvalvular leakage (Supplementary Video 8). The operation time was 90 minutes, the extracorporeal circulation time was 62 minutes, and the cross-clamp time was 38 minutes. The patient was transferred to the intensive care unit, extubated 11 hours after surgery, and experienced a non-complicated postoperative course. He was discharged on the fourth day following surgery. Three months after surgery, the patient was asymptomatic, and follow-up TTE was within normal limits. DISCUSSION In this case, we believe that the bulky calcification with asymmetric distribution on the AV leaflets and the undersized valve prosthesis caused the failed valve deployment. Extensive calcification around the native valve is strongly associated with device failure, especially with self-expanding valves with non-uniform distribution of valvular calcium. 4 percutaneous approach can be attempted at first in the majority of patients with aortic embolization of the TAVR valve. 5 Self-expandable valves can be snared and pulled to a more distal aortic location. However, some reports indicate that such conservative approaches could not always be safe and even be life-threatening, especially with the self-expanding valve, which has an upper crown that may protrude through and perforate the aortic wall. 6 In the present case, even though the valve was embolized into the aorta, the heart team decided on the surgical removal approach due to unstable hemodynamics. In almost all previous cases of surgical removal of embolized TAVR valves, conventional bioprosthetic valves were implanted, so the embolized valve was left useless. 7 Mandegar et al. reported on recapturing and repositioning a displaced balloon-expandable Sapien 3 transcatheter heart valve after LV embolization. 8 CONCLUSION Surgical re-implantation of a dislodged CoreValve is safe, and this approach is feasible in low-income areas with limited availability of prosthetic valves in urgent settings. Declarations Funding : The authors did not receive any funding for this study. Conflicts of interest/Competing interests : None. Data availability: The paper and its Supplementary Information contain all data supporting this study's findings . Code availability : Not applicable. Authors' contributions: Conception and design of the study–S.K.F, S.M.F. Acquisition of data–SMF, S.A.F. Analysis and interpretation of data–A.M.H, M.P Drafting and revision of the manuscript–All authors. Approval of the final version of the manuscript–All authors. Consent: Informed consent for participation and publication was obtained from the participant. References Linke, A. et al. Treatment of aortic stenosis with a self-expanding transcatheter valve: The International Multi-centre ADVANCE Study. Eur. Heart J. 35 , 2672–2684 (2014). Kappetein, A. P. et al. Updated standardized endpoint definitions for transcatheter aortic valve implantation: The Valve Academic Research Consortium-2 consensus document. Eur. Heart J. 33 , 2403–2418 (2012). Geisbüsch, S. et al. Incidence and management of corevalve dislocation during transcatheter aortic valve implantation. Circ. Cardiovasc. Interv. 3 , 531–536 (2010). Larroche, J. et al. Impact of aortic valve calcification severity on device success after transcatheter aortic valve replacement. Int. J. Cardiovasc. Imaging 36 , 731–740 (2020). Alkhouli, M., Sievert, H. & Rihal, C. S. Device Embolization in Structural Heart Interventions: Incidence, Outcomes, and Retrieval Techniques. JACC Cardiovasc. Interv. 12 , 113–126 (2019). Frumkin, D. et al. Valve embolization during transcatheter aortic valve implantation: Incidence, risk factors and follow-up by computed tomography. Front. Cardiovasc. Med. 9 , 1–10 (2022). Iqbal, S., Salmasi, M. Y., Attia, R. Q. & Raja, S. G. Surgical management of misdeployed transcatheter aortic valve due to eccentric leaflet calcification. J. Card. Surg. 36 , 4393–4395 (2021). Mandegar, M. H., Moradi, B. & Roshanali, F. Replacement of a Dislocated Aortic Prosthesis after Transcatheter Valve Implantation. Ann. Thorac. Surg. 101 , e189–e191 (2016). Additional Declarations No competing interests reported. Supplementary Files videocaption.docx videoss.docx Cite Share Download PDF Status: Posted Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. Also discoverable on Platform About Our Team In Review Editorial Policies Advisory Board Help Center Resources Author Services Accessibility API Access RSS feed Manage Cookie Preferences © Research Square 2026 | ISSN 2693-5015 (online) Privacy Policy Terms of Service Do Not Sell My Personal Information {"props":{"pageProps":{"initialData":{"identity":"rs-4601977","acceptedTermsAndConditions":true,"allowDirectSubmit":true,"archivedVersions":[],"articleType":"Case Report","associatedPublications":[],"authors":[{"id":329767977,"identity":"50420163-9383-40fe-801e-acc83320bcad","order_by":0,"name":"Seyed Mohammad Forouzannia","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Mohammad","lastName":"Forouzannia","suffix":""},{"id":329767979,"identity":"8776f883-b04d-4873-b298-543d26a0ee90","order_by":1,"name":"Marziyeh Pakbaz","email":"","orcid":"","institution":"Erfan Niayesh Hospital","correspondingAuthor":false,"prefix":"","firstName":"Marziyeh","middleName":"","lastName":"Pakbaz","suffix":""},{"id":329767980,"identity":"19d77c5d-dee9-4142-824f-09b67d24c2ee","order_by":2,"name":"Ali Mohammad Haji zeinali","email":"","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Ali","middleName":"Mohammad Haji","lastName":"zeinali","suffix":""},{"id":329767981,"identity":"f9154fe5-788f-446c-bb61-ee9d6c770e66","order_by":3,"name":"Seyed Ali Forouzannia","email":"","orcid":"","institution":"Shahid Beheshti University of Medical Sciences","correspondingAuthor":false,"prefix":"","firstName":"Seyed","middleName":"Ali","lastName":"Forouzannia","suffix":""},{"id":329767983,"identity":"925eb2cc-b2b5-41e3-acf3-d0119e5cb5f5","order_by":4,"name":"Seyed Khalil Forouzannia","email":"data:image/png;base64,iVBORw0KGgoAAAANSUhEUgAAAZAAAAAyAQMAAABI0h/eAAAABlBMVEX///8AAABVwtN+AAAACXBIWXMAAA7EAAAOxAGVKw4bAAAA7UlEQVRIiWNgGAWjYDCCA4wPEJwEBhsGBgmCWpgNkLWkkaqFgeEwYS18tw8zPq6oOGzPP7uB7cGDmvOJ/bObDz5gqLGJxqVF8lwys+GZM4eZJe4cYDdIOHY7ccadY8kGDMfSchtwaDE4w39MsrHtMBvDjQQ2iQS224kNN3LMJBgbDuPRwswG0sIjD9by71zifGK1SBiAtCS2HUjcQEiL5BlmZsOGM+kGhmAtfcnGG2+kJQM9hdsvfGeYGR82VFjbywG1SP74Zic770bywQcfamxwakEC/B9ApCNYZQJh5QhgT4riUTAKRsEoGBkAABUFXDQch8EmAAAAAElFTkSuQmCC","orcid":"","institution":"Tehran University of Medical Sciences","correspondingAuthor":true,"prefix":"","firstName":"Seyed","middleName":"Khalil","lastName":"Forouzannia","suffix":""}],"badges":[],"createdAt":"2024-06-18 20:38:22","currentVersionCode":1,"declarations":"","doi":"10.21203/rs.3.rs-4601977/v1","doiUrl":"https://doi.org/10.21203/rs.3.rs-4601977/v1","draftVersion":[],"editorialEvents":[],"editorialNote":"","failedWorkflow":false,"files":[{"id":60944905,"identity":"d2fd15de-f1ad-47ec-9d29-db00635f2654","added_by":"auto","created_at":"2024-07-23 22:16:04","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":1438421,"visible":true,"origin":"","legend":"\u003cp\u003eFluoroscopy showing (A) initial implantation of the self-expanding valve with concomitant root injection. The delivery system is loaded over a J-tipped stiff guidewire with good planar angle positioning in a 5mm depth under the annulus (yellow line); (B) deployment of the inflow part of the self-expanding prosthesis; (C) the moment of complete deployment of the valve in proper position; (D) sudden migration of the valve into to ascending aorta as the delivery system is withdrawn; the yellow arrows point to the calcification of native aortic valve (AV). Transesophageal echocardiography in long axis view of aorta showing (E) the native calcified AV (the red line crossing through it) and the dislodged valve prosthesis with its inflow part positioned just beyond the sinotubular junction (the blue line crossing through it). The object marked by yellow asterisk is the stiff guidewire which still remained in place within the valve stent at this moment; (F) the free-floating valve prosthesis (pointed by yellow arrows) which has migrated more distally within the ascending aorta after removal of all catheters and stiff guidewire.\u003c/p\u003e","description":"","filename":"figure1.png","url":"https://assets-eu.researchsquare.com/files/rs-4601977/v1/1523158a68e7bc3c3ad2ded3.png"},{"id":60945380,"identity":"acbd50ef-fb6c-4591-b28b-87ecd1b9b77c","added_by":"auto","created_at":"2024-07-23 22:24:04","extension":"png","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":1376054,"visible":true,"origin":"","legend":"\u003cp\u003eBailout surgery for removal of the dislodged valve prosthesis: (A) after median sternotomy and pericardiotomy and palpation of the upper and lower pole of valve prosthesis, the innominate and left carotid artery was cross-clamped (yellow arrow) and longitudinal aortotomy was performed (blue arrow); (B) the valve prosthesis was easily removed (yellow arrows); (C) exploration of the native aortic valve showing heavily calcified tricuspid valve with a bulkier calcification on the right coronary cusp (RCC: right coronary cusp, LCC: left coronary cusp, NCC: non coronary cusp)\u003c/p\u003e","description":"","filename":"figure2.png","url":"https://assets-eu.researchsquare.com/files/rs-4601977/v1/8bac1cc77810357e77bcd8ee.png"},{"id":60944907,"identity":"084561be-987d-481e-89ce-ac5f17dd6947","added_by":"auto","created_at":"2024-07-23 22:16:04","extension":"png","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":1214583,"visible":true,"origin":"","legend":"\u003cp\u003ePreparation of the retrieved valve prosthesis for reimplantation: (A) immersing the prosthesis in a sterile bowl of ice-saline; (B) multiple interrupted mattress sutures placed around the prosthesis annulus (C) reimplantation of the prosthesis in the native aortic annulus\u003c/p\u003e","description":"","filename":"Figure3.png","url":"https://assets-eu.researchsquare.com/files/rs-4601977/v1/54122e9cda53a474137da8dc.png"},{"id":64660203,"identity":"47523ff6-0bf0-4d9a-abae-efef381dcb8c","added_by":"auto","created_at":"2024-09-17 07:45:29","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":6868623,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-4601977/v1/061ae083-717d-46d5-b60b-52bc0419678f.pdf"},{"id":60944903,"identity":"8b4e6a9a-ea47-4565-a28b-11043cef3495","added_by":"auto","created_at":"2024-07-23 22:16:04","extension":"docx","order_by":1,"title":"","display":"","copyAsset":false,"role":"supplement","size":13598,"visible":true,"origin":"","legend":"","description":"","filename":"videocaption.docx","url":"https://assets-eu.researchsquare.com/files/rs-4601977/v1/376495940eddff1b17002d16.docx"},{"id":60945379,"identity":"326b718f-6330-4229-a701-7819e82d39c6","added_by":"auto","created_at":"2024-07-23 22:24:04","extension":"docx","order_by":2,"title":"","display":"","copyAsset":false,"role":"supplement","size":14728,"visible":true,"origin":"","legend":"","description":"","filename":"videoss.docx","url":"https://assets-eu.researchsquare.com/files/rs-4601977/v1/c9f132d3056292171db066bc.docx"}],"financialInterests":"No competing interests reported.","formattedTitle":"Surgical Implantation of An Embolized CoreValve transcatheter Self-Expandable aortic bioprosthesis","fulltext":[{"header":"INTRODUCTION","content":"\u003cp\u003eTAVR, in the modern era of valvular disease management, is considered an attractive alternative to surgery in higher-risk patients with symptomatic aortic stenosis.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e TAVR is associated with the potential for serious complications. Valve embolization (VE) is defined as the valve prosthesis movement during or after deployment such that it loses contact with the aortic annulus.\u003csup\u003e\u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e2\u003c/span\u003e\u003c/sup\u003e VE occurs in approximately 0.2% of cases using self-expanding Medtronic CoreValve.\u003csup\u003e\u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e1\u003c/span\u003e\u003c/sup\u003e VE of a partially or entirely deployed CoreValve prosthesis can be managed interventionally in most cases.\u003csup\u003e\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e3\u003c/span\u003e\u003c/sup\u003e Other cases require Aortic Valve (AV) replacement using the conventional surgical approach.\u003c/p\u003e"},{"header":"CASE REPORT","content":"\u003cp\u003eA 78-year-old male was referred to our center with recently diagnosed symptomatic severe aortic stenosis after being evaluated for progressive exertional dyspnea. Transthoracic echocardiography revealed a mean trans-aortic pressure gradient of 56mmHg and AV area of 0.6 cm2 with an ejection fraction of 55%. Coronary angiography revealed minimal non-obstructive coronary artery disease. The patient refused surgical aortic valve replacement (SAVR) despite a low-risk conventional surgery (Society of Thoracic Surgeons Score, 1%); hence, he was scheduled for transfemoral TAVR. Based on the integrated measurements obtained by multi-slice spiral CT angiography, a 34 mm valve prosthesis was suggested; however, regarding the heavy calcification of the AV with a calcium score of 6367, the Heart Team decided to proceed with a 29mm valve prosthesis, to avoid the risk of annular rupture.\u003c/p\u003e \u003cp\u003eTransfemoral TAVR was performed with the aid of transesophageal echocardiography (TEE) (Supplementary Video 1). under general anesthesia, followed by a surgical exploration of the right common femoral artery. After loading the delivery system over a J-tipped stiff guidewire and certainty about good planar angle positioning in a 5mm depth under the annulus (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eA, Supplementary Video 2), the prosthesis was deployed under rapid pacing. With close monitoring by fluoroscopy, the inflow part of the self-expanding prosthesis was first deployed properly (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eB, Supplementary Video 2), followed by expeditious deployment of the outflow part and after the team was satisfied with the valve position, the system was released (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eC, Supplementary Video 2). As the delivery system was withdrawn following full deployment, the valve suddenly migrated into the ascending aorta (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eD, Supplementary Video 3). TEE showed the migrated valve with its inflow part positioned just beyond the sinotubular junction (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eE, Supplementary Video 4). After completely removing the guidewire and pigtail catheter, the final fluoroscopy and TEE images showed the free-floating, fully-expanded CoreValve prosthesis within the distal ascending aorta (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003eF, Supplementary Video 5 and 6). The patient\u0026rsquo;s hemodynamics deteriorated suddenly. Hence, the Heart team proceeded with emergent bailout surgery (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Median sternotomy was performed, and the \u0026ldquo;bouncing\u0026rdquo; valve prosthesis was palpable high in the ascending aorta, with its upper pole near the origin of the innominate artery and the lower pole at a lower point in the distal of the ascending aorta. Under cardiopulmonary bypass, a longitudinal aortotomy was performed (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eA). The stent valve was then retrieved without damage (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eB, Supplementary Video 7) and immediately submerged in ice-cold sterile saline. Cardiac arrest was achieved following direct intra-coronary administration of cardioplegia. The native AV was explored and showed a heavily calcified tricuspid valve with a bulkier calcification on the right coronary cusp, which seemed to be incompressible and resulted in complete immobility of this cusp (Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003eC). The leaflets of the native AV were totally excised, and the annulus debrided of calcification. The heavy calcification of AV extended to the base of the anterior mitral valve leaflet, so decalcification of this valve was also performed. At the next step, the retrieved valve prosthesis was prepared for reimplantation (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Akin to the routine pre-TAVR rinsing and loading procedure, we immersed the prosthesis in a sterile bowl of ice-saline to shrink the nitinol stent frame, especially at the annulus level (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eA). Multiple interrupted mattress sutures encircling the prosthesis annulus were placed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eB). After manual crimping of the lower pole of the stent, the prosthesis was lowered to the native aortic annulus and seated properly, and the sutures were tied and secured (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003eC). Finally, the coaptation of the leaflets was checked, and the aortotomy was closed. The patient was easily weaned off from cardiopulmonary bypass, and the surgery was completed after post-pump TEE, which confirmed the successful result of surgery with normal biventricular function, acceptable leaflet motion, and hemodynamic study (mean trans-aortic pressure gradient of 12mmHg) and a no para or transvalvular leakage (Supplementary Video 8). The operation time was 90 minutes, the extracorporeal circulation time was 62 minutes, and the cross-clamp time was 38 minutes. The patient was transferred to the intensive care unit, extubated 11 hours after surgery, and experienced a non-complicated postoperative course. He was discharged on the fourth day following surgery. Three months after surgery, the patient was asymptomatic, and follow-up TTE was within normal limits.\u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e \u003cp\u003e \u003c/p\u003e"},{"header":"DISCUSSION","content":"\u003cp\u003eIn this case, we believe that the bulky calcification with asymmetric distribution on the AV leaflets and the undersized valve prosthesis caused the failed valve deployment. Extensive calcification around the native valve is strongly associated with device failure, especially with self-expanding valves with non-uniform distribution of valvular calcium.\u003csup\u003e\u003cspan citationid=\"CR4\" class=\"CitationRef\"\u003e4\u003c/span\u003e\u003c/sup\u003e percutaneous approach can be attempted at first in the majority of patients with aortic embolization of the TAVR valve.\u003csup\u003e\u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e5\u003c/span\u003e\u003c/sup\u003e Self-expandable valves can be snared and pulled to a more distal aortic location. However, some reports indicate that such conservative approaches could not always be safe and even be life-threatening, especially with the self-expanding valve, which has an upper crown that may protrude through and perforate the aortic wall.\u003csup\u003e\u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e6\u003c/span\u003e\u003c/sup\u003e In the present case, even though the valve was embolized into the aorta, the heart team decided on the surgical removal approach due to unstable hemodynamics. In almost all previous cases of surgical removal of embolized TAVR valves, conventional bioprosthetic valves were implanted, so the embolized valve was left useless.\u003csup\u003e\u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e7\u003c/span\u003e\u003c/sup\u003e Mandegar et al. reported on recapturing and repositioning a displaced balloon-expandable Sapien 3 transcatheter heart valve after LV embolization.\u003csup\u003e\u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e8\u003c/span\u003e\u003c/sup\u003e\u003c/p\u003e"},{"header":"CONCLUSION","content":"\u003cp\u003eSurgical re-implantation of a dislodged CoreValve is safe, and this approach is feasible in low-income areas with limited availability of prosthetic valves in urgent settings.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003cstrong\u003eFunding\u003c/strong\u003e: The authors did not receive any funding for this study.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConflicts of interest/Competing interests\u003c/strong\u003e: None.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eData availability:\u0026nbsp;\u003c/strong\u003e\u003cstrong\u003eThe paper and its Supplementary Information contain all data supporting this study\u0026apos;s findings\u003c/strong\u003e\u003cstrong\u003e.\u003c/strong\u003e\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eCode availability\u003c/strong\u003e: Not applicable.\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eAuthors\u0026apos; contributions:\u0026nbsp;\u003c/strong\u003eConception and design of the study\u0026ndash;S.K.F, S.M.F.\u0026nbsp;Acquisition of data\u0026ndash;SMF, S.A.F. Analysis and interpretation of data\u0026ndash;A.M.H, M.P Drafting and revision of the manuscript\u0026ndash;All authors. Approval of the final version of the manuscript\u0026ndash;All authors.\u0026nbsp;\u003c/p\u003e\n\u003cp\u003e\u003cstrong\u003eConsent:\u003c/strong\u003e Informed consent for participation and publication was obtained from the participant.\u003c/p\u003e\n\u003cp\u003e\u0026nbsp;\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\n\u003cli\u003eLinke, A. \u003cem\u003eet al.\u003c/em\u003e Treatment of aortic stenosis with a self-expanding transcatheter valve: The International Multi-centre ADVANCE Study. \u003cem\u003eEur. Heart J.\u003c/em\u003e \u003cstrong\u003e35\u003c/strong\u003e, 2672\u0026ndash;2684 (2014).\u003c/li\u003e\n\u003cli\u003eKappetein, A. P. \u003cem\u003eet al.\u003c/em\u003e Updated standardized endpoint definitions for transcatheter aortic valve implantation: The Valve Academic Research Consortium-2 consensus document. \u003cem\u003eEur. Heart J.\u003c/em\u003e \u003cstrong\u003e33\u003c/strong\u003e, 2403\u0026ndash;2418 (2012).\u003c/li\u003e\n\u003cli\u003eGeisb\u0026uuml;sch, S. \u003cem\u003eet al.\u003c/em\u003e Incidence and management of corevalve dislocation during transcatheter aortic valve implantation. \u003cem\u003eCirc. Cardiovasc. Interv.\u003c/em\u003e \u003cstrong\u003e3\u003c/strong\u003e, 531\u0026ndash;536 (2010).\u003c/li\u003e\n\u003cli\u003eLarroche, J. \u003cem\u003eet al.\u003c/em\u003e Impact of aortic valve calcification severity on device success after transcatheter aortic valve replacement. \u003cem\u003eInt. J. Cardiovasc. Imaging\u003c/em\u003e \u003cstrong\u003e36\u003c/strong\u003e, 731\u0026ndash;740 (2020).\u003c/li\u003e\n\u003cli\u003eAlkhouli, M., Sievert, H. \u0026amp; Rihal, C. S. Device Embolization in Structural Heart Interventions: Incidence, Outcomes, and Retrieval Techniques. \u003cem\u003eJACC Cardiovasc. Interv.\u003c/em\u003e \u003cstrong\u003e12\u003c/strong\u003e, 113\u0026ndash;126 (2019).\u003c/li\u003e\n\u003cli\u003eFrumkin, D. \u003cem\u003eet al.\u003c/em\u003e Valve embolization during transcatheter aortic valve implantation: Incidence, risk factors and follow-up by computed tomography. \u003cem\u003eFront. Cardiovasc. Med.\u003c/em\u003e \u003cstrong\u003e9\u003c/strong\u003e, 1\u0026ndash;10 (2022).\u003c/li\u003e\n\u003cli\u003eIqbal, S., Salmasi, M. Y., Attia, R. Q. \u0026amp; Raja, S. G. Surgical management of misdeployed transcatheter aortic valve due to eccentric leaflet calcification. \u003cem\u003eJ. Card. Surg.\u003c/em\u003e \u003cstrong\u003e36\u003c/strong\u003e, 4393\u0026ndash;4395 (2021).\u003c/li\u003e\n\u003cli\u003eMandegar, M. H., Moradi, B. \u0026amp; Roshanali, F. Replacement of a Dislocated Aortic Prosthesis after Transcatheter Valve Implantation. \u003cem\u003eAnn. Thorac. Surg.\u003c/em\u003e \u003cstrong\u003e101\u003c/strong\u003e, e189\u0026ndash;e191 (2016).\u003c/li\u003e\n\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":false,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":false,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"CoreValve, Transcatheter aortic valve replacement","lastPublishedDoi":"10.21203/rs.3.rs-4601977/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-4601977/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eWe report on a case of failed Transcatheter aortic valve replacement (TAVR) in a 78-year-old male, complicated by the dislodgment of a CoreValve into the distal ascending aorta after it was successfully implanted. The case was managed surgically by retrieving and re-implanting the dislodged valve as a bailout strategy.\u003c/p\u003e","manuscriptTitle":"Surgical Implantation of An Embolized CoreValve transcatheter Self-Expandable aortic bioprosthesis","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2024-07-23 22:15:59","doi":"10.21203/rs.3.rs-4601977/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"470369d9-69fa-4eb2-b795-19c0c58d06a6","owner":[],"postedDate":"July 23rd, 2024","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2024-09-17T07:37:20+00:00","versionOfRecord":[],"versionCreatedAt":"2024-07-23 22:15:59","video":"","vorDoi":"","vorDoiUrl":"","workflowStages":[]},"version":"v1","identity":"rs-4601977","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-4601977","identity":"rs-4601977","version":["v1"]},"buildId":"qtupq5eGEP_6zYnWcrvyt","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}