Staged Therapeutic Approach to Concomitant Severe Aortic Stenosis and Atrial Septal Defect: Addressing Dual Mechanisms of Heart Failure—Case Report and Literature Review

Figures

• 

  Figure 1. Post-decongestion echocardiographic reassessment. (A) Degenerative aortic valve disease with severe aortic stenosis (Vmax 4.7 m/s, mean gradient 45 mmHg, AVA 0.53 cm2, AVA index 0.29 cm2/m2) and mild regurgitation; (B) High probability of pulmonary hypertension (non-invasive mean pulmonary artery pressure of 36 mmHg determined using CW doppler early diastolic velocity gradient); (C) Moderate pulmonary regurgitation with dilatation of the pulmonary artery (PA diameter 42 mm); (D) Dilated right ventricle (RV diameter 44 mm, RV/LV ratio >1) with significant RV systolic dysfunction (TAPSE 14 mm, RV s′ 10 cm/s); (E) Severe pulmonary hypertension, demonstrated by consistently increased RV-RA gradient; (F) Severe tricuspid regurgitation on color doppler interrogation.

• 

  Figure 2. Multimodal imaging evaluation of a left-to-right interatrial shunt. (A) TOE—modified bicaval view (100°) demonstrating a large ASD (21 × 21 mm) with left-to-right flow on color Doppler imaging; (B) Zero-degree TOE view showing the hemodynamic impact of the ASD, with marked right heart chamber dilatation and abnormal septal mobility; (C,D) TOE reconstruction illustrating the specific anatomy of the defect, characterized by a small posterior rim and multiple fenestrations consistent with a cribriform septum; (E,F) Cardiac CT demonstrating normal pulmonary venous drainage, a large ostium secundum ASD, and a tricuspid aortic valve with degenerative, calcified cusps.

• 

  Figure 3. Pre-procedural multidetector CT and procedural imaging assessment for TAVI planning and implantation. (A) Favorable iliofemoral access; (B) Tricuspid, heavily calcified aortic valve; (C) Aortic annulus with a mean diameter of 24.4 mm, perimeter of 77.8 mm, and area of 476.2 mm2; (D) Favorable aortic root anatomy; (E) Successful implantation of a 29-mm self-expanding transcatheter aortic valve under combined fluoroscopic and TOE guidance.

• 

  Figure 4. TTE evaluation one month after TAVI. (A,B) Normally functioning aortic bioprosthesis (peak velocity: 1.43 m/s, mean transvalvular gradient: 3.8 mmHg, effective orifice area index: 0.82 cm2/m2) without paravalvular leaks; (C) Persistent, though improved, PH (estimated mPAP: 21 mmHg); (D) Significant improvement in RV systolic performance (TAPSE: 16 mm, RV FWS: −24.3%).

• 

  Figure 5. Right heart catheterization—performed after effective decongestion, optimization of GDMT and TAVI, confirming a significant left-to-right shunt (Qp/Qs: 3.5) and normalization of pulmonary pressures (mPAP: 17 mmHg, PCWP: 9 mmHg, PVR: 0.63 WU).

• 

  Figure 6. Percutaneous atrial septal defect (ASD) closure and follow-up evaluation. (A) Pre-procedural planning: modified bicaval TOE view showing a maximal ASD diameter of 23 mm; (B) Intraprocedural positioning of the occluder device; (C,D) Three-dimensional TOE echocardiographic reconstruction after successful deployment of a 26-mm occluder device; (E) Follow-up at 1 month demonstrating a well-seated device with a small residual shunt; (F,G) Significant improvement in PH (estimated mPAP: 12 mmHg).