1. CoreValve – ICE Awards Italian CoreValve Experts Balloon valvuloplasty after Transcatheter Aortic Valve Implantation (TAVI): always safe? Dr Salvi A, Dr Fabris E, Dr Perkan A Cardiovascular Department, Ospedali Riuniti and University of Trieste, Italy

2. 82 year old man Referred to our Center for a severe symptomatic aortic stenosis Selected by the Heart Team for TAVI because of a high surgical risk (log. EuroSCORE 21%) Diameters of the aortic annulus (on computed tomographic) were 32 x 22 mm, the perimeter was 87 mm A 31 mm CoreValve™ prosthesis (Medtronic, Minneapolis, MN, USA) was selected Dati Basali

3. Intervento Femoral access with a 18 Fr sheath Stiff guidewire was placed in the left ventricle Prosthesis was advanced across the stenotic valve without prior Balloon Valvuloplasty Femoral access with a 18 Fr sheath Stiff guidewire was placed in the left ventricle Prosthesis was advanced across the stenotic valve without prior Balloon Valvuloplasty Sheath cover retracting under fluoroscopic guidance

4. Intervento The position of the CoreValve™ seemed optimal with the distal end 5 mm below the “angiographic” annulus Release of the prosthesis

5. Difficoltà incontrate Good placement but compression of the distal part of the prosthesis Presence of significant aortic regurgitation Good placement but compression of the distal part of the prosthesis Presence of significant aortic regurgitation

6. Soluzione scelta Balloon valvuloplasty (BV) during rapid pacing We performed a BV with a Cristal Balloon 28x50 (Balt, Montmorency, France). The balloon was advanced across the valve and was inflated and deflated during rapid pacing We performed a BV with a Cristal Balloon 28x50 (Balt, Montmorency, France). The balloon was advanced across the valve and was inflated and deflated during rapid pacing

7. Angiography after balloon deflation: acute dislocation of the prosthesis Immagini post-operatorie The valve showed an appropriate expansion but had moved upwards now with the distal part ending apparently just above the “angiographic” annulus

8. The valve seemed anchored without further upward movements The patient was stable Systolic gradient was absent Final angiography showed only a mild AR A persistent good result was documented at follow up echo after two weeks

9. Conclusioni In our case a post implantation balloon valvuloplasty (BV) caused an acute accidental dislocation of CoreValve™ with potential risk of valve embolization BV after CoreValve™ implantation performed without a prior dilatation is an effective procedure but it may cause accidental movements of the prosthesis despite a meticulous technique This may be relevant because the strategy of performing TAVI without balloon predilatation is becoming common In our case a post implantation balloon valvuloplasty (BV) caused an acute accidental dislocation of CoreValve™ with potential risk of valve embolization BV after CoreValve™ implantation performed without a prior dilatation is an effective procedure but it may cause accidental movements of the prosthesis despite a meticulous technique This may be relevant because the strategy of performing TAVI without balloon predilatation is becoming common