Surgical implantation of an aortic over-expanded transcatheter heart valve: a rescue strategy for calcified and aneurysmatic annulus

A 58 year old man from Bolivia presented with pulmonary oedema, transient AV block, and dilated cardiomyopathy (EDD 80 mm; LVEF 30%). A severe isolated aortic regurgitation was discovered. DNA amplification confirmed class C Chagas disease.1 Magnetic resonance failed to identify myocardial fibrosis,2 but a calcified aortic left coronary sinus aneurysm3 (LCSA) was discovered (Figure 1A). Coronary angiography showed absence of stenosis, whereas right heart catheterization excluded pulmonary hypertension. Given the 1.7% STS mortality score, the Heart Team decided for a surgical AV replacement followed by CRT-D. A heart transplant screening was performed as bailout. After full sternotomy, LCSA involvement of the calcified annulus appeared worse than expected. Owed to the impossibility to suture a conventional prosthesis, the only option -similarly to mitral4− was to implant a 29 mm Sapien 3 aortic transcatheter heart valve (THV, Figure 1B and C–E–F): after partial inflation first, 2–0 polyethylene U stitches were placed below RCS/NCS and through the Sapien upper skirt. The prosthesis was nominally inflated, the stitches tied, and a final over-inflation (+4 cc) was performed to cover the huge area.