Early surgical explantation of a TAVI valve for severe hemolytic anemia caused by mild paravalvular leak.

backgroundHemolytic anemia following transcatheter aortic valve implantation (TAVI) is an uncommon complication, particularly in patients with only mild paravalvular leak (PVL). Although reports of TAVI valve explantation are increasing, the procedure remains technically demanding and is associated with high morbidity and mortality. This case highlights the importance of early surgical consideration when hemolytic anemia occurs post-TAVI, despite only mild PVL. CASE PRESENTATION: An 83-year-old man with symptomatic severe aortic stenosis underwent transfemoral TAVI via a 26-mm SAPIEN 3 Ultra RESILIA® valve. Although classified as low surgical risk, TAVI was chosen on the basis of patient preference and age. The procedure was uneventful, with only mild PVL observed via transesophageal echocardiography. The patient was discharged on postoperative day 10. One month later, he presented with fatigue and laboratory findings indicating severe hemolytic anemia. Echocardiography revealed a PVL jet from the non-coronary to left coronary cusp commissure. Preoperative CT revealed bulky annular calcification, especially at the NCC-LCC commissure. Owing to worsening anemia and ongoing hemolysis, surgical explantation and aortic valve replacement were performed. Intraoperatively, a gap was found between the valve and the annulus at the calcified commissure. The TAVI valve was successfully explanted and replaced with a surgical bioprosthesis. Postoperative recovery was uneventful, and hemolysis resolved completely.

conclusionsThis case demonstrates that mild PVL after TAVI may still cause clinically significant hemolysis depending on anatomical features. Careful preprocedural assessment of annular calcification and commissural geometry is critical, even in low-risk patients. Surgical explantation should be considered early when hemolysis occurs, as delayed intervention may lead to increased morbidity. This case reinforces the need for individualized valve selection and close follow-up to address the adverse hemodynamic consequences of PVL promptly, regardless of its apparent severity.