Acute aortic regurgitation following transcatheter aortic valve implantation treated with a pigtail catheter

Abstract

Stuck leaflets of transcatheter aortic valves are a rare but potentially life-threatening complication. Although management often includes immediate valve-in-valve implantation, alternative catheter-based strategies may resolve leaflet immobility and avoid unnecessary interventions. A 78-year-old male with severe symptomatic aortic stenosis (mean gradient 57 mmHg, aortic valve area 0.7 cm²) and high surgical risk (EuroSCORE II 8.9 %) underwent transfemoral balloon-expandable transcatheter aortic valve implantation (TAVI). Post-deployment aortography demonstrated acute severe aortic regurgitation (AR), associated with rapid hemodynamic deterioration. With valve-in-valve implantation under consideration, gentle manipulation (rotation and withdrawal) of an aortic pigtail catheter placed via the left radial artery resulted in immediate resolution of AR, restoration of hemodynamics, and confirmation of leaflet mobility. Catheter-based troubleshooting successfully restored leaflet function without need for additional valve implantation. The patient recovered uneventfully and remained symptom-free at 3-month follow-up echocardiography, with no residual aortic regurgitation. Prosthetic leaflet immobility after TAVI may result from interference by native calcified leaflets, structural trauma during positioning, or incomplete frame expansion. Early recognition and catheter manipulation-such as gentle engagement with a pigtail catheter-can restore leaflet motion and avert emergent valve-in-valve procedures. Careful procedural technique, including precise prosthesis alignment and cautious post-dilatation, may reduce leaflet entrapment risk. In cases of acute severe AR due to stuck leaflets post-TAVI, simple pigtail catheter manipulation should be attempted as a first-line intervention before proceeding to more invasive therapies.