Balloon Rupture During Balloon-Expandable TAVR: Insights Into the Role of Calcium Distribution and Lesion Preparation From Two Cases

Figures

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  Figure 1. Annulus–sinotubular junction anatomy in case 1. (A) CT-derived annular cross-section demonstrating annular geometry for valve sizing. (B) Sinotubular junction cross-section demonstrating marked calcification. (C) CT demonstration of height of the STJ calcification 18.8 mm above annulus plane. CT, computed tomography; STJ, sinotubular junction.

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  Figure 2. Short-axis view of the annulus providing a visual representation of the degree of calcification on the valve, comparing the annular plane view (A) with the outlet view (B) for case 1.

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  Figure 3. Postprocedural TTE apical 3-chamber view continuous-wave Doppler demonstrating mean gradient 10 mm Hg, peak gradient 19 mm Hg, and Vmax of 2.2 m/s across the aortic valve. TTE, transthoracic echocardiography

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  Figure 4. Annular geometry and calcification in case 2. (A) CT scan at the level of the STJ demonstrating no or negligible STJ calcification. (B) CT “hockey puck” view demonstrating an elliptical annulus with severe asymmetric calcification involving the LC, RC, and NC cusps, resulting in a nonuniform mechanical environment during balloon expansion. CT, computed tomography; LC, left coronary cusp; NC, noncoronary cusp; RC, right coronary cusp; STJ, sinotubular junction.

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  Figure 5. Postproceduraltransthoracic echocardiographydemonstrating a transvalvular mean gradient of 4 mm Hg.

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  Figure 6. Postproceduraltransthoracic echocardiographydemonstrating a pressure half-time of 708 ms, consistent with mild aortic insufficiency (AI) following valve implantation.

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  Figure 7. Calcification distribution determines balloon rupture timing and outcome in TAVR. Intravalvular calcification predisposes to early rupture with incomplete expansion and acute aortic regurgitation. Supra-annular calcification permits full expansion prior to rupture, resulting in stable hemodynamics. Procedural considerations include predilatation and optimized balloon positioning. TAVR, transcatheter aortic valve replacement.