Pigtail catheter entrapment during post-dilation causing Sapien-3 Ultra RESILIA valve damage with severe intravalvular aortic regurgitation: a case report

Background Acute prosthetic leaflet dysfunction after transcatheter aortic valve implantation (TAVI) is rare but potentially life-threatening. Catheter-induced leaflet trauma during post-dilatation is less well recognised. Case summary An 88-year-old woman with severe symptomatic aortic stenosis and high-risk aortic root anatomy—including a narrow sinus of Valsalva, low left coronary artery (LCA) height, and a small, calcified sinotubular junction—underwent elective TAVI with a 23-mm Sapien 3 Ultra RESILIA valve deployed with a 2-mL underfill under prophylactic LCA protection. Initial transthoracic echocardiography and aortography showed trivial paravalvular leak and preserved LCA flow. During post-dilatation, the distal balloon tip and Safari guidewire snagged the pigtail catheter, pulling it across the prosthesis and into the left ventricle. Unrecognised in a crowded fluoroscopic field, the catheter became trapped between the expanding balloon and the valve frame, causing focal leaflet injury and severe intravalvular aortic regurgitation with haemodynamic collapse. Emergent valve-in-valve implantation with a 20-mm Sapien 3 Ultra RESILIA under bilateral coronary protection resolved the regurgitation, but displaced leaflet tissue caused LCA ostial compromise requiring chimney stenting. The patient recovered uneventfully and remained stable at 30-day follow-up. Discussion This case illustrates pigtail catheter entrapment during post-dilatation as a preventable cause of acute prosthetic leaflet damage and severe intravalvular regurgitation. It underscores the need for meticulous catheter management, critical reassessment of post-dilatation in older patients with trivial leak, and individualised valve platform and size selection in small, anatomically constrained aortic roots.