Structural Valve Deterioration of a Transcatheter Aortic Bioprosthesis at Four Years in a Young Adult; A Case Aeport

Background Transcatheter aortic valve implantation (TAVI) is the recommended treatment for severe aortic stenosis (AS) in patients ≥ 70 years old or those deemed high surgical risk. While there is growing interest in the expansion if its use to younger, lower risk patients with AS and select groups of patients with bicuspid aortic valve (BAV), it’s use in these individuals remains controversial due to limited durability data and the exclusion of these groups from major randomized controlled trials (RCTs). Case summary A 28-year-old woman with a history of congenital BAV and prior balloon valvuloplasty in infancy, underwent TAVI with a 27 mm SAPIEN-3 valve overseas, aged 24. At four years post-TAVI, she presented to hospital following an episode of presyncope and dyspnea. ECG showed left bundle branch block (LBBB). Echocardiography demonstrated a well seated TAVI but severe restenosis with a maximum velocity of 5.5 m/s and a mean pressure gradient of 79 mmHg. Normal coronaries without ostial compromise and no significant aortopathy was observed on CT coronary angiogram. The patient underwent surgery with a modified Bentall procedure and implantation of a 23 mm St. Jude mechanical valve. Histology revealed degenerative valvular changes without hypoattenuated leaflet thickening. Her post-operative period was unremarkable. Conclusion This case illustrates the potential risks of performing TAVI in a young patient with severely calcified BAV, including conduction disturbance, structural valve degeneration and avoidable intervention to a normal aorta. The paucity of long-term outcome data precludes the use of TAVI in young, low-risk BAV patients and recommended intervention for severe AS in these individuals remains SAVR.