Transcatheter aortic valve implantation (TAVI) is an endovascular alternative to conventional ‘‘open-chest’’ valve replacement in high-surgical risk patients affected by severe aortic stenosis (AS) [1]. Several studies have been published underlining first-generation device performance and mid-term clinical outcomes [2, 3]. The impossibility of complete repositioning of the current transcatheter valves, the Edwards-SAPIEN (ES) aortic valve (Edwards Lifescience, Irvine, California) [2] and the 18 French (Fr) self-expanding CoreValve ReValving System (CRS) prosthesis (Medtronic Inc., MN, USA) [3, 4], is the main limit of these devices. Prosthesis mal-position during TAVI is not uncommon finding [2–4], and it is known that operator’s expertise is crucial in order to prevent any device misplacement and to manage this complication wherever it occurs; however, to date there are no clear indications about the management of these complications yet. Some cases report described the feasibility of the ‘‘Valve-in-Valve’’ technique in case of sub-optimal deployment (‘‘too high’’ or ‘‘too low’’) [5, 6], but the literature lacks in reports which indicate how to treat procedural device migration. Here, we have described a case of procedural CRS migration treated with implantation of a second device. An 81-year-old woman with a diagnosis of severe AS and moderate mitral regurgitation was referred to our Institute for TAVI. She was affected by chronic renal failure and chronic obstructive pulmonary disease, in New York Heart Association (NYHA) functional class IV, with logistic EuroScore 34.97%. During the previous year she was hospitalized four times for congestive heart failure and acute pulmonary edema. The trans-thoracic echocardiogram (TTE) confirmed the severely calcified AS, the mean transvalvular gradient was 65 mmHg, the aortic valve area 0.36 cm and left ventricle ejection fraction was preserved (LV-EF 50%). One month before the procedure the patient underwent a cardiac catheterization which confirmed the severe AS (peak-to-peak transvalvular gradient 90 mmHg); coronary angiography showed a critical stenosis on left circumflex artery treated effectively with two chromocobalt stent implantation; in same session percutaneous aortic balloon valvuloplasty with undersized balloon (16/ 50 mm TyShak, Numed, Hopkinton, New York) was performed with sensible reduction of transaortic gradient (from 90 to 50 mmHg). Thirty days later, TAVI was performed under fluoroscopic and angiographic guidance, in local anesthesia and mild sedation. After the placement of vascular suturemediated system (Prostar XL 10-Fr Abbott Vascular Devices, Redwood City, California) in the left femoral artery, aortic valvuloplasty was carried out during right ventricular pacing, which was well tolerated by the patient with immediate recovery of pressure after pacing; thus, the 18-Fr CRS with a 26-mm prosthesis was positioned across the native valve and we began to deploy it. During the deployment of the distal part of the frame, as the emerging of sinus bradycardia and arterial hypotension, left ventricle perforation by the 0.035-in. stiff guidewire (ASS, Super Stiff, Amplatz Cook Inc., Bloomington, G. P. Ussia M. Barbanti (&) C. Tamburino Division of Cardiology, Ferrarotto Hospital, University of Catania, Catania, Italy e-mail: mbarbantitotti@hotmail.com