TAVR in a 65-Year-Old Man With a Bicuspid Aortic Valve With Extremely Large Annulus and Severe Left Ventricular Dysfunction

J INVASIVE CARDIOL 2020;32(7):E199.

Key words: bicuspid aortic valve, extremely large annulus, cardiomyopathy, transfemoral TAVR

A 65-year-old man presented with worsening dyspnea. Echocardiogram revealed dilated cardiomyopathy with left ventricular ejection fraction (LVEF) of 20% and LV internal diameter of 7.2 cm in diastole, moderate right ventricular dysfunction, severe bicuspid aortic stenosis, and moderate aortic insufficiency (Figure 1A). Gated computed tomography demonstrated a Sieverts type 0 bicuspid aortic valve with extremely large aortic annulus (area 804 mm² and perimeter 102 mm) (Figures 1B-1D). Given severe cardiomyopathy, the heart team decided to pursue transfemoral transcatheter aortic valve replacement (TAVR) with a 34 mm Evolut R transcatheter heart valve (Medtronic) in the hybrid operating room with access for extracorporeal membrane oxygenation if needed.

The patient received conscious sedation with cardiac anesthesia. No general anesthesia was administered due to tenuous blood pressure. Deployment of a 34 mm Evolut R THV was performed with minimal rapid pacing (Figure 1E). Immediately prior to release of the THV, ascending aortogram and echocardiogram demonstrated optimal valve position with mild anterior and posterior paravalvular leak (Figure 1F), so the valve was released. New left bundle-branch block was noted post procedure and patient was discharged home 2 days later with unremarkable course. At follow-up, the patient was noted to have improvement in symptoms and increase in LVEF to 55%.

This case illustrates that transfemoral TAVR is safe and feasible in patients with bicuspid aortic stenosis with extremely large annulus and concomitant severe LV dysfunction. Considerations for THV type and size, anesthesia, hemodynamic support, and open surgical back-up must be taken into account as part of procedural planning.

From the Departments of 1Medicine, ²Anesthesia, and ³Surgery, Stony Brook University Hospital, Stony Brook, New York.

Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. Dr Parikh reports consultant income from Medtronic. The remaining authors report no conflicts of interest regarding the content herein. 

The authors report that patient consent was provided for publication of the images used herein.

Manuscript accepted November 14, 2019.

Address for correspondence: Puja B. Parikh, MD, MPH, FACC, FAHA, FSCAI, Director, Transcatheter Aortic Valve Replacement Program, Stony Brook University Medical Center, Health Sciences Center T16-080, Stony Brook, NY 11794-8160. Email: puja.parikh@stonybrookmedicine.edu