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    "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Transcatheter aortic valve implantation &#40;TAVI&#41; is emerging as an alternative to surgical aortic valve replacement for patients with symptomatic severe aortic stenosis considered to be at high or prohibitive operative risk&#46;<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">1</span></a> We report a case of embolization of an Edwards SAPIEN aortic valve due to sigmoid left ventricular hypertrophy&#44; and discuss potential causes and solutions&#46;</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Case report</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 75-year-old woman diagnosed with severe symptomatic aortic stenosis was referred for TAVI&#46; The patient had a history of diabetes&#44; hypertension&#44; coronary artery disease&#44; morbid obesity&#44; and chronic renal failure&#46; Transthoracic echocardiography &#40;TTE&#41; showed sigmoid left ventricular hypertrophy and ejection fraction of 60&#37;&#44; and Doppler echocardiography revealed a mean aortic gradient of 50 mmHg and an aortic valve area of 0&#46;96 cm<span class="elsevierStyleSup">2</span> &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Figure 1</a>&#41;&#46; Transesophageal echocardiography &#40;TEE&#41; carried out for detailed examination revealed sigmoid left ventricular hypertrophy and an aortic annulus diameter of 24 mm&#46; The aortic annulus diameter measured 26 mm&#215;22 mm on multislice computed tomography&#46; The patient was considered to be at too high risk for surgical aortic valve replacement and was referred for TAVI by a transfemoral approach&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0015" class="elsevierStylePara elsevierViewall">The process was performed under deep anesthesia and transthoracic echocardiographic guidance&#46; The TAVI approach was through the right femoral artery using a 26 mm Edwards SAPIEN valve &#40;Edwards Lifesciences&#44; Inc&#46;&#44; CA&#44; USA&#41;&#46; During balloon inflation under rapid pacing the valve prosthesis immediately embolized into the ascending aorta &#40;<a class="elsevierStyleCrossRef" href="#fig0010">Figure 2</a>&#41;&#46; Attempts to position the valve in the descending aorta were unsuccessful and the bioprosthesis was re-expanded into the aortic arch between the brachiocephalic trunk and the left common carotid artery&#46; At this stage a second Edwards SAPIEN valve was successfully implanted with gradual balloon inflation &#40;<a class="elsevierStyleCrossRef" href="#fig0015">Figure 3</a>&#41;&#46; Arch aortography was carried out which showed no aortic regurgitation and no evidence of obstruction of the left common carotid artery or brachiocephalic trunk&#46; The patient was transferred to the intensive care unit in a hemodynamically stable condition and was discharged one week after the procedure&#46;</p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><elsevierMultimedia ident="fig0015"></elsevierMultimedia></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0020" class="elsevierStylePara elsevierViewall">TAVI is a rapidly emerging treatment option for high-risk and inoperable patient groups&#46; However&#44; this new therapeutic modality raises new questions and problems that need to be identified and resolved&#46; Although less invasive than open-chest aortic valve replacement&#44; TAVI is associated with potentially serious complications&#44; such as valve embolization&#46; Valve embolization during TAVI is a life-threatening complication that requires immediate diagnosis and treatment&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">Procedural embolization of percutaneously implanted valves has been previously reported&#44; with an incidence of 1&#46;01&#37;&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a> Makkar et al&#46; showed that patients with valve embolization had a greater body surface area and were more likely to be male&#46; A cause for embolization was defined in post-procedural operator reports in 73&#37; of cases&#46; The most commonly stated causes were malpositioning&#44; complex annulus&#47;aortic valve anatomy&#44; and pacing failure&#46; Other causes included post-cardiopulmonary resuscitation&#44; post-dilation&#44; cardiac manipulation&#44; displacement during attempted transcatheter valve-in-valve therapy&#44; poor fluoroscopic angle for implantation&#44; and incomplete&#47;delayed device balloon inflation&#46;<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">2</span></a></p><p id="par0030" class="elsevierStylePara elsevierViewall">In our case&#44; distal embolization occurred due to sigmoid left ventricular hypertrophy&#44; an example of complex annulus&#47;aortic valve anatomy&#46; In implantation of an aortic valve via a percutaneous route&#44; the key factors for proper placement and fixation are choice of an appropriate size valve&#44; accurate alignment and correct positioning&#46; One of the most important limitations to the use of the Edwards SAPIEN valve system is sigmoid septum&#44; which can lead to embolization of the prosthesis&#46; In patients with pronounced sigmoid septum&#44; apical placement of the Edwards SAPIEN valve or use of a Medtronic CoreValve are recommended&#46;<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">3</span></a> However&#44; the presence of severe left ventricular hypertrophy and sigmoid septum are also an important predictor for permanent pacemaker requirement after the use of the CoreValve system&#46; In this case&#44; we preferred to use the Edwards SAPIEN valve because of lack of experience in apical placement and the Medtronic CoreValve system&#46; Outcomes of distal aortic embolization of the Edwards SAPIEN valve remain good&#46; The embolized prosthesis may be repositioned into the aortic arch without need for removal or surgery&#46;<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">4&#44;5</span></a></p><p id="par0035" class="elsevierStylePara elsevierViewall">Finally&#44; the precise positioning of the valve&#44; appropriate valve selection&#44; and the route of administration of the procedure appear to be crucial for reducing the risk of valve migration&#46;</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0040" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this study&#46;</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0045" class="elsevierStylePara elsevierViewall">The authors declare that they have followed the protocols of their work center on the publication of patient data&#46;</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0050" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article&#46;</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0055" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare&#46;</p></span></span>"
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        "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Transcatheter aortic valve implantation &#40;TAVI&#41; is considered an alternative therapy in high-risk patients with severe aortic stenosis&#46; Although a minimally invasive procedure&#44; it is not free from complications&#44; one of which is valve embolization at the time of TAVI&#46; We present a case of embolization of a balloon-expandable aortic valve due to sigmoid left ventricular hypertrophy and managed with a second valve without surgery&#46; The embolized valve was repositioned in the aortic arch between the left common carotid artery and the brachiocephalic trunk&#46;</p></span>"
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