Breaking the Limits: Transcarotid Valve-in-Valve Transcatheter Aortic Valve Implantation With Bioprosthetic Valve Fracture in a Small Mitroflow and Extracorporeal Membrane Oxygenation Rescue.

BACKGROUND

Valve-in-valve transcatheter aortic valve implantation (ViV TAVI) in small surgical bioprostheses presents unique challenges due to high residual gradients and risk of coronary obstruction.

CASE SUMMARY: We report a case of an 86-year-old man with a degenerated Mitroflow 19 mm valve who underwent ViV TAVI via transcarotid access using a 20 mm Myval valve. Significant underexpansion was observed post-implantation, with elevated transvalvular gradients. Bioprosthetic valve fracture (BVF) was performed using an 18 mm non-compliant balloon, resulting in full valve expansion and gradient reduction. Shortly after BVF, the patient developed myocardial stunning and hemodynamic collapse, requiring urgent veno-arterial extracorporeal membrane oxygenation (VA ECMO) support. Extracorporeal membrane oxygenation was successfully weaned after 48 hours, and the patient was discharged in stable condition.

CONCLUSION

This is the first reported case of transcarotid ViV TAVI with BVF in a 19 mm Mitroflow bioprosthesis, successfully rescued with ECMO. The report highlights the importance of appropriate access planning, valve selection, and ECMO standby in complex high-risk anatomies.