Balloon Rupture of a Balloon-Expandable Valve in Redo TAVR for Failed Self-Expanding Valve

OBJECTIVE: This study aims to demonstrate a bailout strategy for balloon rupture of the SAPIEN 3 Ultra RESILIA valve during redo transcatheter aortic valve replacement in a calcified, failed Evolut R valve. KEY STEPS: (1) Prompt en bloc removal of the Commander delivery system with the ruptured balloon and 14-F eSheath. (2) Sheath upsizing to 16 F to tamponade potential iliac injury, followed by iliac angiography to confirm the absence of active bleeding. (3) Immediate postdilation of the underexpanded valve to prevent device migration. (4) Endovascular repair of injured iliofemoral arteries using covered stents. POTENTIAL PITFALLS: Abrupt iliofemoral artery rupture may cause hemorrhagic shock. If significant resistance is encountered during removal, en bloc extraction is aborted and the system is repositioned in the aorta for alternative retrieval (eg, contralateral snaring). If hemorrhagic shock occurs after en bloc removal, covered stents were deployed from the abdominal aorta to the femoral access site. If it occurs before removal is complete, emergent surgical repair is required. TAKE-HOME MESSAGES: Severe supra-annular leaflet calcification in prior Evolut R valves may predispose to SAPIEN 3 Ultra RESILIA balloon rupture. A successful bailout strategy includes en bloc removal, sheath upsizing, immediate postdilation, and timely endovascular repair.