Successful transcatheter repair of severe aortic valve stenosis with a fishhook-like calcification

Excerpt

An 84-year-old extreme frail woman presented with symptomatic severe aortic valve stenosis. Transthoracic echocardiography (TTE) revealed a tricuspid aortic valve with eccentric calcification. The aortic annulus area was 399 mm² as observed using multidetector computed tomography (CT), which also revealed a huge fishhook-like calcification extending from the commissure between the left and right coronary cusp to the sinotubular junction through the aortic annulus and the sinus of Valsalva (Fig. 1a–c). Transcatheter aortic valve implantation (TAVI) was scheduled. The calcification was not deformed during intraoperative balloon aortic valvuloplasty, and a cineangiogram during the procedure revealed a balloon indentation on the calcified leaflet (Fig. 1d). CT re-evaluation showed a 22-mm distance between the sinus of Valsalva and the calcified commissure (Fig. 1c). Therefore, a 23-mm SAPIEN XT valve (Edwards Life-science, Irvine California) was implanted with 1 mL filling lesser than the recommended volume. A cineangiogram found that the calcification was not deformed and that the prosthetic valve was mainly expanded toward the noncoronary cusp (Fig. 1e). Postoperative CT showed that the prosthetic valve was implanted in an elliptical shape (Fig. 1f). The patient remains well 12 months after the procedure, with trivial paravalvular leakage on TTE, aortic valve mean pressure gradient of 13 mmHg, and aortic valve area of 1.5 cm².

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