Case presentation
A 89 year female presented with a 10 week history of increasing shortness of breath (SOB) (NYHA III), bilateral ankle odema and occasional paroxysmal nocturnal dyspnoea (PND). Her past medical history was that of atrial fibrillation (AF), hyperlipidemia and hypothyroidism. Her ECG showed left ventricular hypertrophy and rate controlled AF. Chest X-ray revealed cardiomegaly, with bilateral pleural effusions. Her renal functions were normal with an eGFR of 58 and pro BNP measured at 9183. She then had an echocardiogram (ECHO), which diagnosed her to have severe aortic stenosis, with a mean gradient of 53 mmHg and valve area of 0.95 cm2. The Left and Right Ventricular function was preserved. Patient had mild aortic regurgitation, mild-moderate mitral regurgitation and moderate tricuspid regurgitation with estimated pulmonary artery pressure of 50 mmHg. She was then admitted and treated for congestive cardiac failure with intravenous furosemide, which resulted in the resolution of her symptoms.
Coronary angiogram and a TAVI CT were then performed as a workup before patient’s case was discussed in the multidisciplinary meeting. Coronary angiogram revealed mild coronary artery disease. TAVI CT findings were those of an annulus area of 428 mm2 and annulus perimeter of 75 mm, with appropriate left and right coronary heights. The above findings were discussed in the TAVI multidisciplinary meeting, and considering patients age it was decided that percutaneous approach using TAVI was better than surgery to treat patients aortic stenosis.
TAVI was performed via the right femoral artery approach. Balloon aortic valvuloplasty was performed using a 20x40 mm Edwards balloon. Based on CT sizing 23 SAPIEN-3 valve (Edwards Lifesciences, Irvine, California) was implanted with rapid pacing at 180 beats per minute. Post valve deployment ECHO confirmed trivial para-valvular and moderate central aortic regurgitation (AR), with restricted movement of the non-coronary cusp leaflet (Figure 1 and 2; Video 1 and 2). The presence of moderate central AR was confirmed on the aortogram as well (Video 3). The central AR persisted despite different manipulation techniques, such as removal of the wire that was placed in the left ventricle to deploy the valve and repeat crossing of the valve using a pigtail catheter, thus attempting to dislodge the stuck leaflet. We then decided to perform repeat balloon valvuloplasty using the 23x40 mm Edwards balloon, which was overfilled by 2mm. This maneuver was considered, as it could potentially relieve the restricted movement of the leaflet, by mechanically dislodging the leaflet. After preforming the valvuloplasty, the central AR resolved with restored normal movement of the restricted leaflet, this was confirmed on ECHO and aortogram (Figure 3 and 4; Video 4, 5 and 6).