Multifactorial Hemodynamic Collapse during TAVI in a Patient with Basal Septal Bulge and Heavy LVOT Calcification: A Case Report

Objective: This study aimed to describe a life-threatening complication during transcatheter aortic valve implantation (TAVI) in a patient with severe aortic stenosis (AS) and a basal septal bulge and to highlight the procedural challenges associated with this anatomy. Case Presentation: We report an elderly woman with severe AS, heavy annular–left ventricular outflow tract (LVOT) calcification, and a prominent septal bulge. Pre-procedural assessment supported the use of a self-expandable transcatheter heart valve due to calcification extending into the LVOT. After pre-balloon aortic valvuloplasty, acute severe aortic regurgitation (AR) developed, leading to hemodynamic collapse. Urgent valve implantation was performed; however, ongoing instability, chest compressions, and rapid deployment resulted in valve “pop-up,” with persistent AR and cardiogenic shock. Extracorporeal membrane oxygenation (ECMO) was initiated. Subsequent transesophageal echocardiography revealed systolic anterior motion of the mitral valve with acute severe mitral regurgitation, further worsening hemodynamics. A second valve was successfully implanted, the patient stabilized, was weaned from ECMO the following day, and was discharged with favorable hemodynamics. Conclusion: Careful pre-procedural assessment, vigilant intraoperative imaging, rapid heart-team coordination, and the timely use of mechanical circulatory support are essential when performing TAVI in patients with a basal septal bulge.