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Discussion

In the present patient, the ‘Venturi effect’caused by the paravalvular regurgitant jet could explain the early degenerative changes in the bioprosthesis, ultimately leading to a leaflet being fixed in the open position, creating severe valvular regurgitation with a need for high-risk surgical revision. At the time of implantation, transesophageal echocardiography was used as the sole valve-sizing tool. With current expertise and the use of multidetector computed tomography for aortic annulus sizing, the larger 26 mm transcatheter heart valve would have probably been the preferred size (4, 5). Undersizing of the prosthesis relative to the annulus size has been reported as a leading cause for most paravalvular leaks after TAVI (6). A slightly undersized valve, combined with a lower implantation position, resulted in immediate and severe paravalvular regurgitation (see Supplementary videos 1 and 2). Furthermore, valve post-dilatation was not routinely performed at the time of implantation, since it was believed to create valvular regurgitation instead. Today, post-dilatation would have been attempted, but since the implantation position was rather low it remains unclear as to whether this procedure would have been successful in reducing paravalvular regurgitation.