Gutter Rotation Technique for Percutaneous Ipsilateral Retrieval of a Ruptured SAPIEN-3 Balloon

Balloon rupture during transcatheter aortic valve replacement (TAVR) with balloon-expandable valves is a rare but potentially serious complication that may result in incomplete valve expansion, difficult device retrieval, and vascular injury. We report the case of an 88-year-old woman with severe calcific aortic stenosis who underwent TAVR using a 20-mm SAPIEN 3 transcatheter heart valve. Balloon rupture during valve deployment resulted in partial valve expansion and significant paravalvular leak. Conventional retrieval attempts were unsuccessful because the crumpled balloon became entrapped within the posterior expandable segment ("gutter") of the Edwards E-sheath. A novel Gutter Rotation Technique, involving counter-clockwise rotation of the E-sheath with simultaneous clockwise rotation of the Commander delivery system, redirected the balloon toward the rigid portion of the sheath, enabling successful ipsilateral percutaneous retrieval without surgical or contralateral intervention. Valve expansion was subsequently optimized with balloon post-dilatation. This technique may represent a feasible bailout maneuver in selected cases of Type 1 or Type 2 balloon rupture and warrants further evaluation.