Transcatheter aortic valve implantation for a patient with both severe aortic stenosis and membranous ventricular septal aneurysm: a case report

TL;DR

This case report describes a complex TAVI procedure in a patient with severe aortic stenosis and a ventricular septal aneurysm.

Contribution

The paper presents a novel case of TAVI in a patient with a rare anatomical condition, highlighting procedural challenges and solutions.

Findings

Precise annulus measurement is challenging in patients with membranous ventricular septal aneurysm.

Multiple valve sizes were tried to achieve optimal placement and reduce paravalvular leak.

Postoperative echocardiography showed improved left ventricular function.

Abstract

There have been few reports on transcatheter aortic valve implantation (TAVI) for patients with severe aortic stenosis (AS) and a membranous ventricular septal aneurysm (MSA).

A 77-year-old female complaining of dyspnoea was transferred to our hospital. Transthoracic echocardiography (TTE) showed progressive very severe AS with reduced left ventricular (LV) systolic function. The patient was scheduled for TAVI due to high surgical risk. Preoperative computed tomography showed a MSA located between the right coronary cusp and the non-coronary cusp, therefore a part of the annulus rim was lacking. We draw a virtual annulus line to assess her true annulus size and selected a 29 mm size of Evolut Pro Plus. Since the bottom end of the valve was positioned into the MSA, the valve was begun to expand with a lack of coaxiality and massive paravalvular leak (PVL) occurred. Therefore, we decided to retrieve the 29 mm valve. An up-sized 34 mm Evolut was tried, but it was too large and caused the phenomenon of stent-frame infolding. We had to retrieve the 34 mm valve again, and tried to deploy another 29 mm valve at a position as high as possible and pushed the delivery system during the final release to maintain good coaxiality. Postoperative TTE showed significant recovery of LV systolic function, and the PVL was mild.

In patients with both MSA and severe AS, it is difficult to measure the precise annulus size for ensuring stability of the self-expanding valve and preventing PVL.

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