Transcatheter aortic valve replacement with intra-annular self-expanding valve in aortic stenosis with membranous septal aneurysm

An 83-year-old woman presented with dyspnea on exertion and was diagnosed with severe aortic stenosis. Preprocedural multidetector computed tomography revealed a membranous septal aneurysm (MSA) beneath the right–noncoronary commissure, with borderline annular dimensions. Coronary height was low, particularly in the left coronary artery (7.5 mm), and moderate coronary artery disease was also present. Given the uncertainty in annular sizing caused by the anatomical complexity and the more certain preservation of coronary access, transcatheter aortic valve replacement (TAVR) was performed using a repositionable intra-annular self-expanding valve. Balloon aortic valvuloplasty was cautiously performed, and a 25-mm valve was implanted using a cusp-overlap technique and multiple fluoroscopic projections with controlled pacing. Initial deployment was suboptimal; however, a recapturable system enabled appropriate positioning with mild-to-moderate paravalvular leakage (PVL), without conduction disturbances. Follow-up transthoracic echocardiography demonstrated favorable valve function without PVL progression. This case highlights the importance of careful preprocedural assessment and tailored procedural strategy in TAVR for patients with MSA. Learning objective We highlight practical considerations for transcatheter aortic valve replacement (TAVR) in patients with membranous septal aneurysm. This abnormal structure is not particularly rare with modern non-invasive imaging; however, reports of TAVR in this setting remain limited. This case emphasizes the importance of meticulous preprocedural imaging assessment and the advantages of a repositionable intra-annular self-expanding valve for optimal implantation position, preservation of future coronary access, and successful transcatheter therapy despite calcified lower extremity arteries.