Post-implantation transcatheter aortic valve migration in a left ventricular assist device patient with severe aortic insufficiency

A 49-year-old man with dilated cardiomyopathy who underwent HeartMate II (Thoratec) left ventricular assist device (LVAD) implantation 1 year prior presented with cardiac failure secondary to severe aortic regurgitation (AR) requiring inotropic support. He previously developed acute pump thrombosis requiring emergency pump exchange complicated by right heart failure requiring temporary right VAD support. Because of his extreme surgical risk (EuroSCORE-II 48.15%), transcatheter aortic valve implantation (TAVI) was offered on humanitarian grounds. Computed tomography showed an aortic annulus diameter of 27 mm based on its perimeter (86 mm). A 31 mm self-expanding CoreValve (Medtronic) was deployed via the transfemoral approach. Post-deployment, it was satisfactorily positioned with acceptable mild–moderate paravalvular leak (Panels A and B). However, he became haemodynamically unstable 2h post-procedure. Investigations confirmed that the CoreValve migrated into the LV outflow tract, causing severe AR (Panels C and D). Emergency surgery was performed to remove the prosthesis and close the aortic valve. After a complicated post-operative recovery, he was discharged well. We postulate that the early CoreValve migration was contributed by the lack of calcium on the native aortic valve to provide fixation, and the absence of pulsatile flow resulting in the CoreValve leaflets being constantly in a ‘closed’ state, allowing the LVAD to act as a suction to pull it towards the apex. Thus, the application of TAVI in LVAD patients with AR must be viewed cautiously. A possible alternative would be transcatheter aortic valve closure with an Amplatzer Septal Occluder. (Black arrow, intersection of CoreValve with Swan-Ganz catheter on fluoroscopy; white arrow, aortic annulus on echocardiography) P.T.L.C. is a proctor for Edwards Lifesciences and Medtronic CoreValve.