# Fatal outcome after self-expanding transcatheter aortic valve replacement of the bicuspid valve due to infolding: a case report

## TL;DR

A patient with a bicuspid aortic valve experienced fatal complications after TAVR due to valve infolding, emphasizing the need for careful preoperative planning and intraoperative decisions.

## Contribution

This case report highlights the rare but severe complication of valve infolding in bicuspid aortic valve TAVR and provides insights into its management.

## Key findings

- Valve infolding after TAVR in a bicuspid aortic valve led to severe complications and death.
- Comprehensive preoperative anatomical assessment is crucial for high-risk patients undergoing TAVR.
- Prompt recognition and management of valve infolding can potentially prevent fatal outcomes.

## Abstract

Infolding is a rare but potentially life-threatening complication of self-expanding transcatheter aortic valve replacement (TAVR).

We describe the case of an 80-year-old man who was referred for the treatment of severe aortic stenosis complicated by heart failure. Transthoracic echocardiography revealed the following: peak velocity, 6.1 m/s; mean pressure gradient, 102 mmHg; and aortic valve area, 0.26 cm2. Computed tomography (CT) showed a bicuspid aortic valve with a R-L raphe, an annular area of 529 mm2, and a perimeter of 83.4 mm. Considering the patient’s severe emphysema, transfemoral TAVR was performed with the patient under deep sedation. A 34-mm Evolut FX valve was implanted after predilation with a 20-mm Inoue balloon. During deployment up to the point of no recapture, hypotension occurred without improvement, and mild infolding was suspected. However, full deployment was performed, as valve optimization was considered likely to stabilize hemodynamics. Post-deployment balloon dilation was performed; however, valve under-expansion and moderate aortic regurgitation persisted. Initial hemodynamics were stabilized; however, the patient gradually developed respiratory distress. Follow-up CT confirmed substantial valve infolding. Pulmonary hypertension, alveolar hemorrhage, and disseminated intravascular coagulation developed. Surgical aortic valve replacement with a 21-mm valve was performed 15 days post-TAVR. The explanted TAVR valve exhibited marked structural deformation. Although the patient’s circulatory status improved postoperatively, he died of respiratory failure due to pneumonia.

This case highlights the importance of comprehensive preoperative anatomical assessment and intraoperative decision making in high-risk patients, particularly those with bicuspid valves. Valve selection (considering the valve type and size) must be meticulously tailored to the anatomical features surrounding the annulus. In addition, upon its recognition, substantial infolding should be promptly addressed by recapturing the valve, adjusting the valve size, or redeploying the valve with additional balloon aortic valvuloplasty.