Modified balloon-assisted shoehorn technique for transcatheter aortic valve implantation in functionally horizontal anatomy: a case report

Background Transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve (BAV) poses unique challenges. We report a case in which an apparently benign anatomy resulted in failure of conventional delivery strategies and required a novel balloon-assisted bailout technique. Case summary A 59-year-old man with a background history of liver cirrhosis presented with severe aortic stenosis due to type 1 BAV. The patient was in Child-Pugh class A with MELD score of 14, hence he was planned for TAVI in view of high surgical risk. Pre-procedural computed tomography showed a favorable LV-Aortic angle, but the fused non-coronary and right-coronary cusp behaved like functional horizontal anatomy. Various previously described wire and balloon-assisted techniques failed to deliver the valve. A novel balloon-assisted modified “shoe-horn” technique, by inflating a 16 mm balloon in non-coronary sinus, altered the delivery trajectory and enabled successful valve delivery. Discussion BAV with right-noncoronary cusps fusion may behave like horizontal anatomy, despite favorable LV-Aortic angle. A modified balloon-assisted shoe-horn technique can facilitate valve delivery when conventional methods fail. This case highlights an underrecognized mechanism of valve delivery failure in BAV and emphasizes the importance of preparedness for advanced bailout strategies.