Managing Severe Bicuspid Aortic Stenosis, Aortic Coarctation, and Impaired Left Ventricular Function

Figure 1. Anatomical Challenges (A and B) A horizontal aortic arch, as visualized on computed tomography (CT) and angiography in a left anterior oblique (LAO) projection, respectively. (C and D) A juxtaductal aortic coarctation with a minimal lumen diameter of 4.0 mm, assessed by CT angiography (C) and invasive angiography (D). (E) A three-dimensional CT reconstruction of the aorta following stent implantation, illustrating the postprocedural anatomy.

Figure 2. Computed Tomography Assessment of the Aortic Valve and Root Anatomy (A) Aortic annulus measurements showing severe calcification and an elliptical shape with an annular area of 398.7 mm2 and perimeter of 71.5 mm. (B) Evaluation of the sinuses of Valsalva: 28.5 mm (right), 32.6 mm (left), and 37.6 mm (noncoronary). The annular-to-coronary distance is ≥10 mm. (C) Intercommissural distance (ICD) of 23.8 mm, with visible asymmetric leaflet opening. (D) Multiplanar reconstruction identifying focal calcification at the base of the cusps, without evidence of raphe calcification. The valve is classified as Sievers type 1 (right-left cusp fusion), without significant raphe calcification.

Figure 3. Echocardiographic Assessment (A and B) Apical 4-chamber and parasternal long-axis views from the initial transthoracic echocardiogram showing severely reduced left ventricular systolic function (LVEF: 12%) with low-gradient aortic stenosis (mean gradient: 20 mm Hg). (C and D) Corresponding echocardiographic views 2 weeks after treatment of aortic coarctation with a covered stent. Notable improvement in left ventricular ejection fraction (LVEF: 32%) is observed, along with an increased aortic mean gradient (42 mm Hg), consistent with improved forward flow following reduction of afterload mismatch.

Figure 4. Contralateral Snaring Technique to Facilitate Crossing of a Recently Implanted Aortic Stent (A) Initial setup showing a high-support wire advanced into the left ventricle through a GooseNeck snare positioned from the contralateral femoral artery. (B) Valvuloplasty balloon interacts with the distal stent edge, posing a risk of stent deformation or displacement. (C) Gentle traction on the snare and guiding catheter repositions the balloon centrally within the stent, minimizing the risk of stent damage. (D-F) Same technique applied during transcatheter heart valve (THV) advancement, with the snare engaged at the junction between the nosecone and delivery catheter. (E) Despite optimal centralization of the THV by snare traction, significant friction is observed during advancement, resulting in slight bending of the proximal stent skirt—a characteristic feature of this valve's navigational behavior (black arrow head).

Figure 5. Implantation of Self-Expanding Valve in a Horizontal Aorta (A) Near-cusp overlap view with parallax removed; the distal edge of the valve is positioned 2-3 mm above the non-coronary cusp. (B-D) Slow deployment under rapid pacing at 180 beats/min, with the delivery system supported against the outer curvature of the ascending aorta. During deployment, gentle traction on the delivery catheter was applied to centralize the valve and align it with the level of the left coronary sinus (arrowheads). (D) At 80% release, the implantation depth is approximately 4-5 mm. (E) Final result without parallax, with an implantation depth of approximately 5 mm relative to the annular plane. No residual regurgitation and a final transvalvular gradient of 5 mm Hg.