Cardiac CT provides uniquely accurate and comprehensive assessment of bioprosthetic aortic valve stenosis

An 81-year-old man was referred to the cardiology clinic with breathlessness and angina. His history included triple-vessel coronary artery bypass graft (CABG) plus St Jude Epic 21 mm bioprosthetic aortic valve replacement (AVR) surgery 7 years prior. Transthoracic echocardiography (TTE) demonstrated severely elevated Doppler AVR velocities (VMax 4.7 m/s) and severe AVR stenosis (valve area 0.7cm2). This was the suspected cause of symptoms, and transfemoral valve-in-valve AVR valve-in-valve transcatheter aortic valve implantation (VIV-TAVI) was being considered. However, TTE image quality was suboptimal due to echocardiographic windows and valve echogenicity, precluding accurate leaflet assessment (figure 1A–D). Transoesophageal echocardiography corroborated TTE findings (VMax 5.5 m/s) but failed to delineate the mechanism of AVR restriction (figure 1E–H). Degenerative leaflet calcification was evident on echocardiography, however echogenicity around the sewing ring prevented distinction between calcification and pannus, and ultrasound dropout precluded thrombus exclusion. Figure 1 Top row (transthoracic echocardiography): (A) Parasternal long-axis view with limited AVR visualisation (open-headed arrow) with increased echogenicity which can be due to pannus, calcification or metallic valve components; (B) turbulent antegrade colour-Doppler flow; (C) apical five-chamber view with limited AVR visualisation (open-headed arrow); (D) severely elevated antegrade AVR velocities on continuous-wave Doppler (VMax 4.6 m/s) suggestive of severe valve stenosis/obstruction. Bottom row (transoesophageal echocardiography): (E-G) …