September 13, 2025JACC Case ReportsOpen Access

Dual Percutaneous Repair for Aortic Annulus Rupture After Balloon-Expandable TAVR

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Why the study?

Aortic annulus rupture is a rare but life-threatening complication of TAVR that requires individualized management.

Structured PICO

Population

An 85-year-old man with severe degenerative aortic stenosis (mean gradient: 46 mm Hg, aortic valve area: 0.9 cm²), moderate aortic regurgitation, and a minimally calcified tricuspid aortic valve, with a history of hypertension, dyslipidemia, and chronic coronary syndrome with preserved LVEF (prior stenting in 2021).

Intervention

Dual percutaneous management of aortic annulus rupture comprising a valve-in-valve procedure (implantation of a self-expanding 29-mm aortic bioprosthesis) for supra-annular rupture and percutaneous coil embolization via a retrograde left radial approach for subannular pseudoaneurysm.

Outcome

Technical success of percutaneous exclusion of both supra-annular rupture and subannular pseudoaneurysm, and patient clinical recovery.safety

This case demonstrates that life-threatening sequential supra-annular and subannular ruptures following TAVR can be successfully managed entirely percutaneously using valve-in-valve implantation and coil embolization.

Implication

Supports percutaneous coil embolization for select post-TAVR ruptures in high-risk elderly patients; leaves open need for prospective safety data.

Abstract

BACKGROUND: Aortic annulus rupture is a rare but life-threatening complication of transcatheter aortic valve replacement (TAVR), often linked to balloon-expandable valves and anatomic risk factors. CASE SUMMARY: An 85-year-old man with severe aortic stenosis underwent successful transfemoral TAVR. Two hours later, he developed tamponade because of a supra-annular rupture. A second, higher-positioned valve was implanted, followed by a third prosthesis after valve migration. Days later, a subannular rupture with pseudoaneurysm was identified. Coil embolization via radial access achieved complete exclusion. DISCUSSION: Annulus rupture may occur at various levels (supra-, intra, or subannular) and requires individualized management. This case highlights a staged rupture progression and successful percutaneous management, offering a less invasive alternative for high-risk patients. TAKE-HOME MESSAGES: Annulus rupture is a rare but critical TAVR complication. Rapid diagnosis and multidisciplinary coordination are essential. Percutaneous strategies, including valve-in-valve and coil embolization, may be lifesaving in selected cases.