Presentations

Abstract

Introduction: This case report focuses on the treatment of a patient with critical aortic stenosis via transcatheter aortic valve replacement (TAVR) which demonstrates the unusual complication of TAVR valve infolding. Risk factors for TAVR infolding include heavy calcification, which this patient exhibited. An Evolut valve was used for this procedure. We posit that careful attention to preimplant valve preparation reduces the likelihood of infolding, as demonstrated by this case in which two successive valves showed infolding ultimately relieved by aggressive valvuloplasty.

Case Information: The patient is a 69-year-old female with a history of five syncopal episodes over past two years. Physical exam was notable for stable vital signs with BMI 40, 3/6 systolic murmur with late peak, and 1+ edema. Transthoracic echocardiogram showed severe aortic stenosis. The patient's aortic stenosis was successfully treated with TAVR, with the final transaortic gradient by echocardiogram being 80 → 11 mmHg in this highly stenosed bicuspid valve.

Discussion/Clinical Findings: This case focuses on the treatment of a patient with a bicuspid aortic valve with heavy calcification - TAVR was employed and valve infolding occurred twice before a valve was successfully put in place. An initial balloon valvuloplasty was performed. Subsequent implantation of a self-expanding supra-annular valve resulted in infolding. This was identified, and after a new valve was prepared and deployed, it again showed infolding. More aggressive balloon dilatation with full expansion at high pressure allowed the third and final prepared valve to be safely deployed without recurrent infolding. The first and second TAVRs were infolded due to heavy calcifications surrounding the patient's aortic valve. Thus, repeated balloon aortic valvuloplasty was performed with a high-pressure balloon, which allowed the third TAVR to be successfully inserted.

Conclusion: Overall, TAVR infolding occurred twice due to heavy calcifications around the patient's aortic valve. Following balloon aortic valvuloplasty, the calcifications were compressed, allowing the third TAVR to be successful.