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A 81-year woman was admitted to our institution due to worsening chronic heart failure. The patient presented herself with severe aortic valve stenosis and mitral valve insufficiency. Due to estimated high operative risk a TAVI approach was chosen. Following the fist TAVI implantation (Sapien XT™ 26 mm) a big paravalvular leakage was diagnosed. Hence, in order to close the paravalular leakage, a second TAVI procedure with a Core Valve™ 26 mm was performed. A following CT scan showed signs of aortic ring rupture. We therefore decided to perform open heart surgery. After removal of both TAVI prosthesis, native valve excision a 21 mm sized aortic homograft was implanted. Additionally, a mitral valve annuloplasty with CE Physio™ 28 mm ring was performed. In the postoperative period the patient remained for three weeks in the ICU, followed by two weeks on general ward. The patient was discharged home in good condition, with good left ventricular function and regular homograft function in the aortic position. The open heart surgery should have had been performed primarily. Nevertheless, the decision on the treatment strategy is always difficult in case of borderline patients.

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