case_images: PMC10914981_01
case_images: Baseline two-dimensional (2D) transesophageal echocardiography (TEE) color Doppler at mid-esophageal 5 chamber view (A), at deep transgastric 5 chamber view (B) and mid-esophageal AV long-axis view (C,D) showing a 26 mm SE evolut  R  with moderate to severe regurgitation (yellow arrow) through a long, tortuous paravalvular leakage below the left coronary sinus (white arrowheads). La, left atrium; LV, left ventricle; AV, aortic valve.
case_images: fcvm-11-1359711-g001.jpg
case_images: PMC10914981_01_fcvm-11-1359711-g001.jpg
case_images: F1
case_images: Over time, the residual regurgitation increased to moderate to severe through a 10 mm long and 4 mm in diameter, tortuous, heavily calcified leak located below the left coronary sinus (Figure 1, Supplementary Videos S1-S3).
case_images: Fluoro-angiographic intra-procedural procedural steps (1). Left anterior oblique (A) and right anterior oblique (B) aortography with a Pig-tail 5-Fr catheter showing severe regurgitation (white arrows) through a highly calcified paravalvular leak of a self-expandable transcatheter aortic valve (TAVI) (26 mm Evolut  R ); white asterisks indicate the large calcific nodules in the annular region. The stiff guidewire (GWBC30, Medtronic Confida ) (yellow arrow) from the aorta crossed the tortuous calcified leak retrogradely and, after forming a loop in the left ventricle, was advanced over the TAVI prosthetic leaflets into the descending aorta where it was snared and externalized through the left femoral artery, thus creating an arterio-arterial loop (C). A 6-Fr Multipurpose guiding catheter was advanced over the exchange stiff wire to the entry of the leak. Subsequently, the leak was crossed with an additional 0.0014 coronary guidewire (PILOT, Abbott Vascular) advanced into the left ventricle and then into the aorta and predilated with non-compliant (NC) balloon dilatation catheters (D).
case_images: fcvm-11-1359711-g002.jpg
case_images: PMC10914981_01_fcvm-11-1359711-g002.jpg
case_images: F2
case_images: Severe paravalvular aortic regurgitation with a high burden of calcium between the prosthesis frame and native tissue was demonstrated by left and right anterior oblique (LAO/RAO) aortography (Figures 2A,B). The hydrophilic guidewire was replaced with a stiffer guidewire (GWBC30, Medtronic Confida ) which, after creating a loop in the LV, was advanced across the self-expandable valve into the descending aorta where it was snared and externalized through the left femoral artery, thus creating an arterio-arterial loop (Figure 2C). Subsequently, the leak was crossed with an additional 0.0014 coronary guidewire (PILOT, Abbott Vascular) advanced into the LV and then into the aorta, predilated with NC Euphora  2 x 15 mm (Medtronic) and Accuforce 4 x 20 mm (Terumo) non-compliant balloon dilatation catheters at 12 atm to engage the PVL with the Shockwave balloon (Figure 2D).
case_images: Fluoro-angiographic intra-procedural steps (2). A Shockwave balloon C2 IVL 3 x 12 mm (white arrow) was positioned within the leak and inflated with low pressure to prevent annular rupture (A). The application of the IVL to the calcified leak and the increased support provided by the Confida guidewire finally allowed the progression of the 6-Fr dedicated delivery sheath (Occlutech ODS III) into the left ventricle (B). A specifically designed, 5 mm square twist device (PLD, Occlutech, Helsingborg, Sweden) (orange arrows) was successfully deployed and released within the leak (C,D).
case_images: fcvm-11-1359711-g003.jpg
case_images: PMC10914981_01_fcvm-11-1359711-g003.jpg
case_images: F3
case_images: Due to the heavy concentric calcifications within the leak and in order to avoid annular rupture, a Shockwave Lithotripsy balloon 3.0 x 12 mm was positioned within the leak and inflated at low pressure for a total of 80 pulses during two shockwave cycles (Figure 3A). The application of IVL for the highly calcified leak and the increased support provided by the Confida guidewire finally allowed the 6-Fr dedicated delivery sheath (ODS III, Occlutech) to advance into the LV (Figure 3B). A specifically designed, 5 mm ST PLD was successfully deployed within the leak (Figures 3C,D).
case_images: Post-procedure 2D TEE color Doppler in the mid esophageal AV long-axis view (A,B) and 2D X-plane TEE AV long-axis/short-axis views (C) showing SE TAVI (26 mm evolut  R ) with trivial/mild residual intra-leak regurgitation and the correct position of the 5 mm PLD deployed within the leak (orange arrows). La, left atrium; LV, left ventricle; AV, aortic valve.
case_images: fcvm-11-1359711-g004.jpg
case_images: PMC10914981_01_fcvm-11-1359711-g004.jpg
case_images: F4
case_images: Follow-up 2D TEE color Doppler 1 and 3 months following the procedure confirmed the stable position of the device with trivial residual leak (Figure 4).