Transfemoral TAVR in Chronic Type A Aortic Dissection and Severe Aortic Stenosis

Figures

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  Visual Summary. Clinical Timeline of TAVR in a Patient With Severe Bicuspid AS and Chronic TAAD (A) Transthoracic echocardiography showing severe aortic stenosis (AS) with high transvalvular gradient. (B) Computed tomography (CT) demonstrating chronic type A aortic dissection (TAAD) with preserved true lumen and no malperfusion. (C) Fluoroscopic image showing valve crossing through the true lumen. (D) Transesophageal echocardiography (TEE) during valve deployment under imaging guidance. (E) Follow-up CT at 12 months showing no progression of the aortic dissection. HF = heart failure; LVEF = left ventricular ejection fraction; TAVR = transcatheter aortic valve replacement.

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  Figure 1. Preprocedural TAVR CT Assessment in a Patient With Chronic TAAD and Severe Bicuspid Aortic Stenosis (A) Axial computed tomography (CT) reconstruction at the aortic annular level showing annular planimetry. (B) Axial CT slice at a supra-annular level demonstrating the dissection flap within the ascending aorta, confirming chronic type A aortic dissection (TAAD), with visible separation between the true and false lumens. (C) Curved multiplanar reconstruction showing the right coronary artery ostium (RCA). The relationship between the coronary ostium and the dissection flap is appreciated. (D) Three-dimensional volume-rendered reconstruction of the aortic arch and proximal descending aorta. A red asterisk indicates the false lumen, demonstrating the extent of the dissection beyond the ascending segment and into the aortic arch. (E) Cross-sectional image at the renal artery level showing the right renal artery (RRA) arising from the false lumen (red asterisk), whereas the left renal artery originates from the true lumen. This finding confirms distal extension of the dissection to the infrarenal segment without significant visceral malperfusion. (F) Three-dimensional volume-rendered…

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  Figure 2. Detailed Computed Tomography–Based Transcatheter Aortic Valve Replacement Planning in a Patient With Chronic Type A Aortic Dissection and Bicuspid Aortic Stenosis (A) Axial view at the aortic annular level showing annular planimetry. The right coronary cusp (RC), left coronary cusp (LC), and non-coronary cusp (NC) are labeled. Measurement markers delineate the annular dimensions for prosthesis sizing. (B) Fluoroscopic projection simulation (angiographic view) displaying the predicted optimal C-arm angulation for valve deployment (right anterior oblique [RAO] 15°, caudal [CAU] 18°). (C) Three-dimensional hockey puck maximum intensity projection (MIP) reconstruction at a cranial angulation (RAO 7°, cranial [CRA] 16°), providing a volumetric overview of the aortic root and annular geometry. (D) Curved multiplanar reconstruction (MPR) of the descending aorta showing the course of the dissection flap along the thoracoabdominal aorta. This sagittal view demonstrates the relationship between the true and false lumens and confirms the extent of the chronic dissection, aiding in guidewire navigation planning to ensure true lumen access throughout the procedure. (E) Double oblique MPR at…

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  Figure 3. Intraprocedural Imaging During Transcatheter Aortic Valve Replacement in a Patient With Chronic Type A Aortic Dissection (A) Fluoroscopic image demonstrating the self-expanding transcatheter valve prosthesis during deployment at the aortic annular position. (B) Intraprocedural transesophageal echocardiography showing a view of the aortic root after valve deployment. The prosthesis is visualized in a well-seated position within the native annulus. Transesophageal echocardiography guidance was used throughout the procedure to confirm true lumen positioning; to monitor for potential complications such as dissection propagation, pericardial effusion, or significant paravalvular leak; and to assess immediate hemodynamic results. No procedural complications were observed.

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  Figure 4. Echocardiographic Assessment Pre– and Post–Transcatheter Aortic Valve Replacement (A) Preprocedural transthoracic echocardiography with continuous-wave Doppler across the aortic valve confirming severe aortic stenosis. Hemodynamic parameters demonstrate a peak velocity (Vmax) of 3.91 m/s, gradient of 39.57 mm Hg, and a velocity-time integral (VTI) of 107.7 cm, consistent with the severe bicuspid aortic stenosis described in the clinical evaluation (aortic valve area 0.8 cm2, Doppler velocity index 0.20). (B) Postprocedural transesophageal echocardiography demonstrating an improvement in transvalvular hemodynamics after self-expanding valve implantation. Doppler parameters show a markedly reduced Vmax of 1.19 m/s and a mean gradient of 2.72 mm Hg, indicating normal prosthetic valve function without significant residual obstruction.

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  Figure 5. CT Comparison Pre– and Post–Transcatheter Aortic Valve Replacement Demonstrating Stable Chronic Type A Aortic Dissection (A) Preprocedural computed tomography (CT) multiplanar reconstruction in a sagittal oblique view showing the ascending aorta, aortic arch, and aortic root. The dissection flap is visualized in the ascending aorta originating approximately 2 cm above the annular plane. The severely calcified bicuspid aortic valve is seen at the base of the aortic root. The dilated ascending aorta (47 mm) and the relationship between the true and false lumens are clearly delineated. (B) Preprocedural three-dimensional volume-rendered reconstruction providing a detailed view of the aortic root, ascending aorta, and cardiac structures. The native calcified bicuspid aortic valve is visualized in situ. The dissection flap is appreciated in the ascending aorta, and the coronary arteries arising from the true lumen are identified. This reconstruction aided in procedural planning and spatial orientation of the dissection relative to the aortic root. (C) Postprocedural CT multiplanar reconstruction at 12-month follow-up showing the self-expanding transcatheter valve prosthesis well…