Abstract
Objective
This case report presents the successful application of transcatheter aortic valve replacement using the TaurusElite valve in a high-risk patient with severe calcified type 0 bicuspid aortic valve and aneurysmal dilation of the ascending aorta. The report highlights using a snare-assisted technique to navigate complex anatomical challenges.
Key Steps
Preoperative multimodal imaging for precise anatomical assessment. A snare-assisted delivery system navigation ensures controlled passage through the aortic arch and valve. Balloon predilation and careful valve deployment at 2 mm above the annulus. Postdeployment confirmation of valve position and coronary perfusion.
Potential Pitfalls
Risk of paravalvular leak due to severe calcification and asymmetric valve anatomy. Potential for coronary obstruction or aortic injury during valve deployment. Challenges in navigating a narrow aortic arch and aneurysmal dilation.
Take-Home Message
TAVR with adjunctive techniques like snare-assisted navigation is a viable option for high-risk patients with complex BAV anatomy, emphasizing the importance of meticulous preoperative planning and precise valve positioning to minimize complications.
Key Words: aortic aneurysm, aortic stenosis, bicuspid aortic valve, snare-assisted technique, transcatheter aortic valve replacement
Graphical Abstract
Aortic stenosis (AS) is one of the most common valvular heart diseases, exhibiting an up-trending incidence with advancing age.1 AS is mainly caused by calcification, bicuspid aortic valve (BAV), and rheumatic disease. BAV, a common congenital heart defect (1%-2% prevalence), is classified into types 0 (7%), 1 (88%), and 2 (5%) by the Sievers system.2,3 China has a higher BAV prevalence, especially type 0, among transcatheter aortic valve replacement (TAVR) patients compared with the West, with the most severe aortic regurgitation, largest aortic dimensions, and poorest prognosis in Asia.4 In the clinic, AS patients can present with symptoms such as angina, syncope, and heart failure. Since the first successful TAVR in 2002, TAVR has emerged as a critical treatment option for symptomatic AS patients who have a high surgical risk or contraindications to the traditional surgical approach. TAVR has the advantages of safety and minimal invasiveness, with a high success rate.5 In this study, we present a case of a 60-year-old female patient with type 0 severe calcified BAV accompanied by aneurysmal dilation of the ascending aorta. We described this patient's treatment strategy and outcomes to provide a reference for the clinical management of patients with similar illnesses.
Take-Home Messages
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TAVR is a viable option for high-risk patients with severe calcified type 0 BAV and an ascending aortic aneurysm, mainly when adjunctive techniques like snare-assisted navigation are utilized to overcome complex anatomical challenges.
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Comprehensive preprocedural imaging, precise valve selection, and optimal implantation depth are essential to reducing complications such as paravalvular leak and coronary obstruction, highlighting the need for patient-specific strategies in complex BAV cases.
Case Summary
A 60-year-old woman presented with recurrent chest tightness and shortness of breath for over a year. Her medical history included coronary atherosclerosis and hypertension. An outpatient echocardiogram showed moderate AS and regurgitation, ascending aortic dilation, left heart hypertrophy, and left ventricular wall thickening. She was hemodynamically stable on admission, with normal breath sounds and a grade 3/6 systolic murmur at the right sternal border. No peripheral edema or jugular vein distention was observed.
The laboratory tests were normal, including complete blood cell counts, coagulation function, liver function, renal function, electrolytes, and N-terminal pro–B-type natriuretic peptide level. The electrocardiogram reported regular sinus rhythm, premature atrial beats, and ST-T abnormalities. The echocardiographic examination demonstrated an aortic valve annulus diameter of 19 mm, aortic sinus inner diameter of 37 mm, aneurysmal dilation of the proximal ascending aorta of 53 mm, enhanced echogenicity in aortic valve with restricted motion, accelerated aortic valve systolic blood flow, peak flow velocity of 5.9 m/s, pressure gradient of 139 mm Hg, a moderate amount of blood flow reflux signal during diastolic aortic regurgitation with a peak flow velocity of 4.3 m/s and pressure gradient of 76 mm Hg, left atrial anteroposterior diameter of 41 mm, left ventricular anteroposterior diameter of 51 mm, left ventricular ejection fracture of 56%, and fractional shortening of 30%. The computed tomography angiography showed a shallow myocardial bridge in the anterior descending branch, left ventricular wall thickening (diastolic septum thickness ∼18 mm), aortic valve calcifications, widened ascending aorta (∼56 mm), and aneurysmal dilation at the left common carotid artery's origin. The heart was enlarged, with a calcified plaque in the abdominal aortic wall. Preoperative assessments included computed tomography evaluation, aortic root and supravalvular measurement (BAV with annulus diameter of 22.1 mm and ascending aorta dilation, valve leaflet thickening with severe calcifications and a score of 1,060 mm3) (Figure 1), coronary obstruction risk, and peripheral vascular access. The patient was scheduled for TAVR surgery.
Figure 1.
Aortic Root and Supravalvular Structure Measurement
A longitudinal clefted bicuspid aortic valve, annular diameter of 22.1 mm, left ventricular outflow tract, and aneurysmal dilation of the ascending aorta of 56 mm. Thickened valve leaflets with severe calcifications were mainly distributed on one side of the valve leaflets and the commissure of the two sinuses. The calcification score was 1,060 mm3.
Procedural Steps
Preoperative preparation and vascular access
The procedure was performed under general anesthesia with transthoracic echocardiographic guidance. The patient was placed in a supine position under general anesthesia. The surgical field was disinfected. A temporary pacemaker was placed through the left subclavian vein. Vascular access was obtained via a 6-F vascular sheath through the right brachial artery, and a pigtail angiography catheter was introduced into the ascending aorta for imaging. Then, the right femoral artery was punctured and fitted with a 7-F vascular sheath; a 6-F EBU3.5 guiding catheter was advanced along the guidewire to the left coronary ostium. Ultimately, the left femoral artery was accessed, and after the placement of 2 ProGlide vascular suture devices (Abbott), an 8-F arterial sheath was inserted.
Balloon predilation
Aortic root angiography revealed a limited opening of the aortic valve. An 18-mm balloon was used twice for predilation to facilitate the passage, producing a slight “waist sign” with no contrast agent leak and ensuring that left coronary artery perfusion remained normal (Figures 2A and 2B). The coronary artery protection guidewire was withdrawn.
Figure 2.
Implantation of Artificial Aortic Valve
(A) Aortic root angiography, limited aortic patency, and 2 full predilations with an 18-mm balloon. (B) Mild “waist sign,” no contrast leak. (C, D) With the snare assistance, the TaurusElite delivery system successfully passed through the aortic arch and valve. The AV23 valve was released at 0 mm above the valve annulus, resulting in deep positioning of the valve. Therefore, the artificial valve was retrieved. (E, F) The AV23 valve was released at 2 mm above the valve annulus during the second attempt. The valve morphology and position were satisfactory at its working position. The coronary blood perfusion was normal. There was no paravalvular leak after the valve was anchored to the annulus. No abnormality was identified in the aortic arch angiography.
Snare-assisted valve delivery technique
The snare-assisted method improves delivery system control, ensuring precise positioning even with complex aortic root anatomy. Given the patient’s type 0 BAV, characterized by the absence of a raphe, with severe calcification (score: 1,060 mm3) and aortic dilation, a snare-assisted technique was employed to control the delivery system’s passage. The Amplatz GooseNeck Snare (15-25 mm; Medtronic) was selected, with a transfemoral approach for valve delivery and a transradial/brachial approach for snare guidance. The primary approach advanced a super-rigid guidewire (eg, Confida [Medtronic]) into the left ventricle. At the same time, the snare, introduced via the accessory route, captured the distal end of the guidewire, forming a “U-ring.” The snare was then gradually tightened to retract the guidewire toward the aortic arch or descending aorta, shortening its effective length, enhancing support, and optimizing axial alignment. With continuous snare traction synchronized with the advancement of the delivery system, the system was successfully guided across the aortic valve. After confirming the proper position and deployment of the valve, the snare was released and withdrawn, ensuring the integrity of the guidewire and the absence of vascular injury.
Valve deployment and intraoperative adjustments
The AV23 valve was released at 0 mm above the valve annulus. After confirmation of the deep positioning of the valve, the delivery system was retracted (Figures 2C and 2D). A second attempt was performed with the AV23 valve released at 2 mm above the annulus. The valve morphology and position were satisfactory in the working position, with normal coronary artery blood perfusion. Repeat angiography confirmed no abnormality (Figures 2E and 2F), and postoperative transthoracic echocardiography demonstrated no paravalvular leak around the aortic valve, with a pressure gradient of 9.04 mm Hg.
Bailout techniques for intraoperative challenges
In cases in which the snare-assisted technique was not used upfront or when intraoperative difficulties arise—such as failure to advance the delivery system, guidewire instability, or valve displacement—several bailout techniques may be employed. These include adjusting the guidewire to optimize coaxial alignment, utilizing emergency snare remediation for realignment and stabilization, applying the buddy wire technique to enhance support, or adopting a retrograde crossing approach by advancing a secondary wire from an alternate access site. These techniques serve as rescue strategies to prevent procedural failure and mitigate complications when encountering challenging anatomical constraints.
Considerations for valve selection
In TAVR for type 0 BAV, valve selection critically depends on root anatomy and calcification distribution. Balloon-expandable valves offer superior radial support to reduce the risk of paravalvular leakage, particularly in cases with severe asymmetric calcification and a small root angle. Although precise implantation is required, balloon-expandable valves ensure better sealing and controlled deployment, making them preferable for this case to optimize valve anchoring and minimize complications. In our case, there was no paravalvular leak after the valve had been anchored to the annulus.
Potential Pitfalls
The preoperative evaluation indicated moderate difficulty anchoring the valve due to severe calcification, which increased the risk of paravalvular leak. The artificial valve’s placement required careful adjustment to prevent deformation and root damage. The left valve leaflet extended beyond the coronary ostia attachment edge, increasing the risk of left coronary artery obstruction. Given the dimensions of the sinus of Valsalva, intraoperative balloon dilation was performed with attention to maintaining coronary perfusion.
The patient’s 61° annular angle, narrow aortic arch, and ascending aortic aneurysm (56 mm) posed challenges in crossing the valve and arch, elevating the risk of dissection and rupture. Compared with tricuspid aortic valves, BAV patients have more complex anatomy and a higher risk of complications post-TAVR. Studies indicate that BAV-AS patients undergoing TAVR face increased paravalvular leaks, particularly with self-expanding valves. In contrast, balloon-expandable valves, though providing better sealing, may heighten the risk of aortic injury. A thorough anatomical assessment is essential for device selection and procedural planning to mitigate these risks.5
Conclusions
This case highlights the successful application of TAVR in a high-risk patient with severe calcified type 0 BAV and aneurysmal dilation of the ascending aorta. A snare-assisted technique facilitated safe navigation through a complex aortic arch, while the balloon-expandable TaurusElite valve (Peijia Medical) provided controlled deployment and optimal annular sealing. Key lessons include the importance of multimodal imaging for preoperative planning, the utility of adjunctive techniques in challenging anatomies, and the need for careful valve positioning to ensure coronary perfusion. As TAVR continues to evolve, this case underscores its potential as a viable alternative to surgery in patients with complex BAV anatomy, provided that procedural strategies are tailored to individual anatomical challenges. However, a balloon-expandable valve was not used in our case due to cost concern. Further research is warranted to refine techniques and improve outcomes in this high-risk population.
Footnotes
The authors attest they are in compliance with human studies committees and animal welfare regulations of the authors’ institutions and Food and Drug Administration guidelines, including patient consent where appropriate. For more information, visit the Author Center.
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