In a patient with severe LVOT calcification, a 23-mm balloon expandable Myval was successfully deployed despite abnormal asymmetric expansion, resulting in no annular damage or paravalvular leak.
Case Report (n=1)
Excessive LVOT calcification can cause abnormal, asymmetric expansion of balloon-expandable transcatheter heart valves, requiring careful sizing and positioning to prevent annular damage.
A 70-year-old female presented with shortness of breath, NYHA Class II symptoms for the past year, which had progressed to NYHA Class III over the past 2 months. She also complained of dizziness on exertion. On examination, the patient had a harsh late peaking ejection systolic murmur in the right second intercostal space. Echocardiographic evaluation revealed severe calcific aortic stenosis with a gradient of 110/60 mmHg. Given the presence of significant comorbidities including morbid obesity, uncontrolled diabetes, and severe obstructive sleep apnea, after heart team discussion, the patient was referred for Transcatheter Aortic Valve Implantation. Computed tomography (CT) angiography revealed a calcified tricuspid aortic valve with a relatively small aortic annulus Figure 1. CT angiography also showed a porcelain aorta with diffuse and severe calcification and a significant amount of calcium protruding from the left coronary cusp into the left ventricular outflow tract (LVOT) Figure 2. Figure 1: Computed tomography analysis using 3mensio Medical Imaging, Utrecht, Netherlands software of the aortic valve at the annulus (a) and left ventricular outflow tract level (b). The area-derived diameter at both levels was 21. 7 mm, while the perimeter-derived diameter was 22 mmFigure 2: (a) Computed tomography Angiography using 3mensio software, demonstrating diffuse and severe calcified porcelain aorta. (b) significant calcification from the left coronary cusp extending into the left ventricular outflow tractA 23-mm balloon expandable Myval was deployed across the native aortic valve under rapid pacing. Normally, the balloon expandable aortic valve expands equally at both ends, and in later stages of inflation, the waist in the middle portion of the valve is abolished. However, in this patient, due to excessive LVOT calcification, the upper part of the valve expanded considerably and asymmetrically compared to the lower end of the valve Figure 3a and b and Video 1. After the upper part of the valve had completely expanded, the lower part of the valve began to expand Figure 3c and Video 1. Figure 3: (a and b) Abnormal deployment of the valve with expansion of the upper end of the valve (white arrow) before the lower end (black arrow). (c) late expansion of the lower end of the valve "href": "Single Video Player", "role": "media-player-id", "content-type": "play-in-place", "position": "float", "orientation": "portrait", "label": "Video 1. ", "caption": "", "object-id": {"pub-id-type": "doi", "id": "", "pub-id-type": "other", "content-type": "media-stream-id", "id": "1ᵧvlr94hu", "pub-id-type": "other", "content-type": "media-source", "id": "Kaltura"} Postdeployment angiography revealed no aortic regurgitation and adequate deployment of the valve with preserved coronary flow. Echocardiography showed trivial paravalvular regurgitation, and postdeployment gradient of 8/3 mgHg, which was confirmed with invasive measurements using a pigtail catheter. Due to careful valve selection, sizing, and deployment, we could ensure that there was no damage to the annular structure, which can be catastrophic. The patient transiently developed a new onset of left bundle branch with QRS duration of 130 ms postprocedure, which resolved spontaneously within 6 h of valve deployment. She was discharged without the need for a pacemaker implantation and is doing well on follow-up for the past 6 months. It is important to be aware of excessive LVOT calcification and anticipate an abnormal sequence of valve expansion in these cases. Extra precautions regarding valve sizing and positioning of the valve are needed to prevent annular damage and paravalvular leak. An individualized approach is needed in these cases, as patient anatomy and physiology dictate the choice between balloon versus self-expanding valve, with slightly higher rates of pacemaker implantation noted with self-expanding valves, compared to slightly higher rates of annular rupture noted with balloon expanding valves. 1 Declaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient has given her consent for her images and other clinical information to be reported in the journal. The patient understands that name and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.
Prasad et al. (Wed,) conducted a case report in Severe calcific aortic stenosis (n=1). Transcatheter Aortic Valve Implantation (balloon expandable Myval) was evaluated. In a patient with severe LVOT calcification, a 23-mm balloon expandable Myval was successfully deployed despite abnormal asymmetric expansion, resulting in no annular damage or paravalvular leak.