Rheumatic Bicuspid Aortic Valve Causing Device Embolization during Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has emerged as a feasible alternative for treatment of severe aortic stenosis with comparable outcomes to surgical aortic valve replacement (SAVR) in recent years. We present a case of device embolization in the left ventricular outflow tract (LVOT) during TAVR in a patient with severe aortic stenosis that required emergent surgical intervention. During the open-heart surgery for embolized prosthesis extraction and SAVR, both TEE exam and surgical specimen demonstrated bicuspid aortic valve and rheumatic nature of the valve with lack of calcification, which were identified to be the two main factors that contributed to the complication. In which the insufficient annular calcification increases the risk of device embolization due to lack of an adequate landing zone for device anchoring, and the anatomy of bicuspid valve contributes to the complication due to its associated large annular size and horizontal aorta. This case highlights device embolization as one possible complication of TAVR which is associated with substantial morbidity and mortality, the clinical management process was thoroughly documented with aortic angiography and transoesophageal echocardiography imaging.