How should I treat a left ventricular outflow tract-migrated balloon-expandable transcatheter heart valve?

An 85-year-old female patient with small body habitus (body mass index of 23.1 kg/m 2 , body surface area of 1.5 m 2 ) and medical history of lymphoma in remission and atrial fibrillation on new oral anticoagulants was referred to our institutional Heart Team for consideration for transcatheter aortic valve implantation (TAVI). The patient was in NYHA Class IV heart failure. Her echocardiogram showed normal left ventricular function, severe calcified aortic stenosis with valve area of 0.6 cm 2 , and peak/mean gradient of 61/36 mmHg. The patient was frail, her Society of Thoracic Surgeons (STS) risk score for mortality was 5.3%, and her EuroSCORE II was 3.4%. Accordingly, it was decided to proceed with TAVI using the transfemoral approach. Pre-procedural computed tomography showed mildly calcified aortic valve leaflets (Figure Due to right bundle branch block in her baseline electrocardiogram putting her at high risk for post-procedure complete heart block, a 23 mm SAPIEN XT transcatheter heart valve (Edwards Lifesciences, Irvine, CA, USA) was chosen for TAVI. The procedure was performed under conscious sedation and a satisfactory position of the SAPIEN XT valve was achieved (Figure The procedure was completed uneventfully. Upon transfer of the patient from the catheterisation lab bed to the stretcher, the patient developed complete atrioventricular block and a temporary pacemaker was re-inserted. The patient was haemodynamically CASE SUMMARY BACKGROUND: A high surgical risk patient with severe aortic stenosis underwent transcatheter aortic valve implantation.