Objective: We report a case of left ventricular perforation during transfemoral transcatheter aortic valve implantation (TAVI) caused by significant tortuosity of the access route that affected the guidewire.

Case Presentation: An 89-year-old woman with severe aortic stenosis was admitted to our hospital for TAVI. Computed tomography revealed an extremely tortuous descending thoracic aorta characterized by an acute bend without calcification. Our heart team decided to perform transfemoral TAVI because it is minimally invasive. A standard 14-French e-sheath (Edwards Lifesciences, Irvine, CA, USA) was inserted, and a Safari2 (Boston Scientific, Marlborough, MA, USA) guidewire was advanced into the left ventricle. Subsequently, a Lunderquist wire (Cook Medical, Bloomington, IN, USA) was introduced as a buddy wire to facilitate delivery of a Sapien3 23-mm (Edwards Lifesciences) transcatheter heart valve (THV). However, significant tortuosity of the thoracic aorta remained. During manipulation of the delivery system for THV depth adjustment, the tortuosity of the thoracic aorta unexpectedly straightened, causing the Safari2 guidewire to penetrate deeply into the left ventricular apex. After the deployment of the THV, the patient’s blood pressure decreased due to cardiac tamponade. An open chest hemostatic procedure successfully identified and repaired the bleeding point at the left ventricular apex, allowing for patient recovery.

Conclusion: Severe tortuosity of the access route can affect guidewire manipulation and increase the risk of left ventricular perforation. This emphasizes the critical importance of precise anatomical evaluation and careful approach selection in cases of TAVI with significant tortuosity of the access route.