Massive aortic regurgitation following paravalvular balloon valvuloplasty of an Edwards SAPIEN valve treated by emergent CoreValve implantation: never cross a transcatheter aortic valve without a pigtail.

A 72-year-old patient, with a history of coronary artery bypass and aorto-bifemoral graft, was diagnosed with a symptomatic severe aortic valve stenosis in the presence of moderately decreased left ventricular function. The Heart team decision was to implant an Edwards SAPIEN XT 26 mm valve by transapical approach, therefore avoiding access through the aorto-bifemoral graft. At the end of the procedure, grades 2-3 aortic regurgitation was observed. Since each run of rapid pacing ended in ventricular fibrillation, it was decided to treat the aortic regurgitation conservatively with the option of post-dilation in a second procedure if hemodynamic deterioration was observed. Six days later balloon valvuloplasty was performed because of heart failure requiring endotracheal intubation. Despite transesophageal echocardiography guidance the balloon was inadvertently advanced through the paravalvular space. As a consequence, balloon valvuloplasty was complicated by massive aortic regurgitation and severe hemodynamic instability which was resolved after emergency transfemoral implantation of a CoreValve. Without any further complications, the patient was discharged eight days later.