Transcatheter Valve-in-Valve implantation after late migration of balloon expandable Sapien-XT prosthesis in a severe pure aortic regurgitation case

A 76-year old female, was admitted in our cardiac surgery clinic to perform surgical aortic valve replacement due to a severe aortic regurgitation with symptoms of congestive heart failure. Her past medical history included moderately impaired renal function (GFR 48 mL/min) and arterial hypertension.  The thoracic-CT scan revealed a serious calcification of the entire thoracic aorta (Figure 1). Due to the porcelain aorta, in contrast to the low logistic Euroscore (1.7%) favoring surgical aortic valve replacement, we proceed transcatheter aortic valve implantation (TAVI). The TAVI performed with the use of Edward-Sapien-XT prosthesis 29 mm under general anesthesia and transesophageal guidance. The periprocedural transesophageal echocardiography (TOE) and angiogram demonstrated a good result immediately after implantation without relevant bioprosthesis malfunction/migration or residual aortic regurgitation (Figure 1). Post procedure, an increase in the preexisting left bundle block with QRS-duration of 150 msec demonstrated in the electrocardiographic (ECG). A permanent pacemaker DDD-Modus was implanted prophylactically. At postoperative day 7, the pre-discharge TOE revealed that the prosthesis had migrated into the left ventricular outflow tract (LVOT) beneath the level of the native valve, accompanied with a severe residual native aortic regurgitation (NAR). Furthermore, the migrated transcatheter heart valve (THV) in the ventricle was in a contact with the anterior mitral leaflet without accompanying signs of mitral valve dysfunction. A flutter motion of the prosthetic valve leaflet anatomically oriented at right coronary commissure attached on the posterior aortic wall was demonstrated as a