A valve embolized twice: a case report of Sapien 3 embolization in left ventricle and left atrium during transcatheter transapical mitral valve-in-valve implantations for a failed bioprosthesis

Background: Transcatheter mitral valve-in-valve (TMVIV) using the Sapien 3 (Edwards Lifesciences, Irvine, CA, USA) transcatheter heart valve is associated with high technical success and sustained valve performance. However, complications may occur or be detected during or after the procedure.

Case summary: We herein describe a rare case of a 59-year-old female who underwent TMVIV for a failed surgical mitral bioprosthesis. During the procedure, the device was embolized twice into the left ventricle and left atrium, respectively, resulting from the crimped transcatheter valve partially detaching from the balloon of the Certitude delivery system during passage through a tight transapical sheath. Fortunately, we were able to catch the dislodged valve and anchor it by the partially inflated device balloon, followed by successful repositioning and deployment.

Discussion: In cases where the valve has already detached, as in the present case, the sheath may be advanced against the proximal end of the valve as a pusher, providing good support to push the entire system to cross the bioprosthesis. Then, the delivery catheter should be withdrawn with the counteraction of the sheath in order to correct the interrelated positions of the valve and the balloon. Finally, the valve can be positioned and deployed after the sheath is withdrawn.