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

## TL;DR

This case report describes a successful transcarotid valve-in-valve TAVI procedure with balloon valvuloplasty and ECMO rescue in a high-risk patient.

## Contribution

First reported case of transcarotid ViV TAVI with bioprosthetic valve fracture in a 19 mm Mitroflow valve rescued by ECMO.

## Key findings

- Transcarotid ViV TAVI with BVF in a 19 mm Mitroflow valve achieved full valve expansion and reduced gradients.
- ECMO was successfully used to rescue the patient after hemodynamic collapse following BVF.
- The case highlights the importance of access planning, valve selection, and ECMO readiness in complex procedures.

## Abstract

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.

Valve-in-valve (ViV) transcatheter aortic valve implantation (TAVI) is a valuable alternative to re-do surgery in patients with structural valve degeneration.