Figure 1. Pre-TAVI CT assessment of bicuspid aortic valve: measurement of the aortic annulus, Valsa...

Figure 2. Preoperative cardiac catheterization. Patent left coronary artery without significant angi...

Figure 3. Left main coronary artery protection with guidewire and drug-eluting stent (3A). Balloon p...

Figure 4. Transcatheter aortic valve implantation of a 23-mm balloon-expandable MyVal device (4A). S...

Introduction

Aortic stenosis (AS) is one of the most prevalent valvular heart diseases, affecting 1.3% of individuals over 65 years of age. About 0.7% present moderate-to-severe disease1. Severe degenerative AS is predominantly seen in older adults; therefore, its prevalence is increasing due to population aging. In contrast, bicuspid aortic valve (BAV) is a congenital condition that adds further complexity due to asymmetric calcification and higher risk of coronary obstruction, making multimodality planning and protective strategies critical2.

Cardiogenic shock (CS) along severe AS carries a poor prognosis. To date, the safety and efficacy of transcatheter aortic valve implantation (TAVI) in CS remain controversial3. Previous studies in patients with AS and CS undergoing successful balloon aortic valvuloplasty (BAV) reported 30-day mortality rates ranging from 33% to 47%, 1-year mortality rates of 70%, and 2-year mortality rates of up to 90%. Therefore, this conservative therapy leads to poor outcomes in these patients. In this context, TAVI has emerged as a less invasive alternative with superior outcomes compared with BAV and favorable results versus surgery in select patients4.

Recently, in 2023, the European Heart Journal published results from a large real-world observational study from the United States showing that contemporary balloon-expandable S3 and S3U valves are a safe and effective treatment option for patients with CS. The in-hospital and 30-day mortality rates after TAVI in CS patients were 9.9% and 12.9%, respectively, which are considerably lower than the previously reported 35%–70% mortality rates in patients treated conservatively5. In a European multicenter registry including 51 patients with severe aortic valve disease and CS treated with TAVI, the device success rate was 94.1%, with 30-day and 1-year mortality rates of 11.8% and 25.7%, respectively6.

We report an urgent TAVI procedure in a patient with bicuspid aortic valve and CS requiring left main coronary artery protection and chimney stenting, with excellent immediate outcomes.

Clinical case

The patient was a 43-year-old sedentary man. His past medical history included diagnosis of aortic stenosis (AS) during childhood. There was no prior pharmacological treatment. He had been recently diagnosed with de novo heart failure 3 months earlier requiring hospitalization. Doppler echocardiography showed a non-dilated left ventricle (LV), left ventricular ejection fraction (LVEF) 58%, double aortic valve lesion, severe AS with a peak gradient of 137 mmHg and a mean gradient of 92 mmHg, and mild aortic regurgitation. He was initially assessed by the Department of Cardiovascular Surgery, where outpatient preoperative studies were requested in preparation for surgical aortic valve replacement (SAVR). The patient progressively deteriorated over a short period of time, with marked weight loss and worsening functional class (FC, III–IV), prompting readmission to the Coronary Care Unit due to decompensated heart failure in cardiogenic shock, with NT-ProBNP 30,700 ng/L. On physical examination, his general condition seemed to be poor, with evident nutritional impairment and body weight 46.7 kg (body mass index [BMI]: 16.1 kg/m2). Stabilization treatment was initiated with IV diuretics and inotropic support. Admission ECG revealed sinus rhythm, QRS 120 ms, poor R-wave progression in the anterior leads, and left anterior fascicular block. Repeat Doppler echocardiography reported a mildly dilated LV with severe reduction in LVEF (20%) and critical AS, with an aortic valve area of 0.5 cm². The patient remained in cardiogenic shock, requiring inotropic support, with severe LVEF reduction, and marked nutritional compromise (consistent with cardiac cachexia). His STS score predicted mortality of 8.5% (for SAVR) and his EuroSCORE II was 21.2% for mortality. After being assessed by the Heart Team, the patient was deemed high surgical risk with an indication for urgent TAVI.

Computed tomography angiography before TAVI

Findings included bicuspid aortic valve with a calcium score of 3472, leaflet thickening, and significant calcification. There was no atherosclerotic disease in the aorta. However, there was mild dilatation of the ascending aorta in the tubular segment. Two supra-aortic trunks had preserved diameters, with common origin of the brachiocephalic trunk and left common carotid artery. The dimensions for the aortic annulus were 24 mm (coronal) and 20 mm (sagittal), with a 69-mm perimeter. The aortic root (sinus-to-sinus) was 28 mm. The distance from the valve to the left coronary ostium was 7 mm, and 4 mm to the right coronary ostium; 5.7 mm to the left common iliac artery; 6 mm to the right common iliac artery; 5.3 mm to the left external iliac artery; 4.6 mm to the right external iliac artery; 5 mm to the left common femoral artery; 5 mm to the right common femoral artery; 4 mm to the left superficial femoral artery, and 4 mm to the right superficial femoral artery.

Procedure. Transcatheter aortic valve
implantation (TAVI)

Under neuroleptoanalgesia, vascular access was obtained with 7-Fr introducers via the right and left femoral arteries and the right femoral vein for temporary pacemaker implantation. Right radial access was also achieved. Subsequently, a VL3 6-Fr guiding catheter was positioned in the left coronary artery via the right femoral artery and a 0.014” guidewire with a 4.0×24-mm coronary stent was advanced and parked in the distal left anterior descending artery for coronary protection due to the low takeoff of the left coronary ostium. A 6-Fr pigtail catheter was placed in the aortic root via the right radial access and an AL2-6-Fr catheter, via the left femoral access. The aortic valve was crossed with a straight-tip 0.035” guidewire, with a baseline transaortic gradient of 80 mmHg, and exchanged for a Surpass SF 0.035” guidewire placed at the left ventricular apex. Then, it was exchanged by a 14-Fr introducer in the left femoral artery, and balloon predilation of the aortic valve was performed with a 20×40-mm Mammoth balloon. A 23-mm balloon-expandable MyVal transcatheter aortic valve (Meril Life Sciences, Vapi, India) was then implanted under pacing using a deflectable Navigator delivery catheter, thus eliminating the transaortic gradient. Final post-placement angiography confirmed adequate transcatheter valve positioning with no significant paravalvular leak and sinus rhythm. Upon severe residual stenosis of the left main coronary artery (due to displacement of the native leaflet causing partial ostial obstruction), a 4.0×24 mm sirolimus-eluting BIOMIME stent (Meril Life Sciences, Vapi, India) was successfully deployed at 14 atm with a chimney technique. Control angiography confirmed left coronary artery patency, with no residual stenosis. Percutaneous closure of the left femoral artery was then performed without complications with a Proglide system (Abbott Cardiovascular, Santa Clara, CA, USA). Control angiography of the left common iliac artery revealed a retrograde dissection at the distal external iliac artery, partially flow-limiting; prolonged balloon angioplasty with a 5.0×40-mm balloon was successfully conducted, thus restoring normal distal flow. Hemostasis of the right femoral and right radial arteries was achieved by local compression. The patient remained hemodynamically stable throughout the procedure without complications and was transferred to the Coronary Care Unit for further monitoring. Hospital discharge occurred 48 hours after the procedure.

Figure 3. Left main coronary artery protection with guidewire and drug-eluting stent (3A). Balloon predilation of the aortic valve with a 20×40-mm Mammoth balloon (3B).

At 30-day and 3-month clinical/echocardiographic follow-up, the patient remained in NYHA functional class I with preserved transvalvular gradients, no paravalvular leak, 60-% LVEF, and no need for reintervention or adverse events.

Discussion

In patients with severe aortic stenosis (AS), CS can significantly worsen the prognosis and limit therapeutic options. Mortality associated with TAVI in patients with CS remains significantly higher compared to those without CS. Several studies have reported in-hospital mortality rates in patients with AS and CS undergoing TAVI ranging from 25% to 50%, whereas in patients without CS these rates are considerably lower, usually below 15%7. This difference may be attributed to the hemodynamic complexity of CS, which involves severe ventricular dysfunction and systemic compromise, two factors that increase perioperative risk and limit post-procedural recovery8.

However, TAVI shows lower early mortality rates than conservative management with simple valvuloplasty, and comparable or superior results to surgery in selected patients, with differences ranging between 10% and 20% in favor of TAVI9. This advantage is mainly explained by the lower invasiveness, the avoidance of open-heart surgery, and the shorter recovery time, which is particularly critical for hemodynamically unstable patients.

The use of TAVI in patients with bicuspid aortic valve (BAV) disease and CS remains a clinical challenge, given the peculiar anatomy and the critical hemodynamic status of these patients. Computed tomography determines the risk of coronary occlusion (heights < 10–12 mm, small sinuses), justifying preventive strategies such as BASILICA or chimney protection. In our case, the low coronary height and calcified bicuspid morphology prompted active protection and subsequent chimney stenting of the LMCA, with adequate final patency. Given the young patient age, the need for long-term planning (lifetime management), and the odds of requiring ViV (valve-in-valve) reintervention, valve durability and coronary access became central in the decision-making process.

Conclusion

In this patient with CS and bicuspid aortic valve, TAVI was a viable lower-risk treatment alternative compared to conventional surgery, allowing for hemodynamic stabilization and faster recovery. Appropriate case selection, CT-based planning, and a multidisciplinary approach were decisive in optimizing the clinical outcome.

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2. Siu S, Silversides C. Enfermedad de la válvula aórtica bicúspide. J Am Coll Cardiol. 2010;55(25):2789–800. doi:10.1016/j.jacc.2009.12.068.

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8. Makkar RR, Jilaihawi H, Chakravarty T, et al. Association between transcatheter aortic valve replacement for cardiogenic shock and outcomes: insights from the STS/ACC TVT Registry. JAMA Cardiol. 2019;4(6):579-87.

9. Kaneko T, Vemulapalli S, Thourani VH, et al. Comparison of clinical outcomes in patients with cardiogenic shock undergoing transcatheter versus surgical aortic valve replacement: analysis from the TVT Registry. J Am Coll Cardiol. 2018;71(11):1187-96.

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TAVI in a patient with severe bicuspid aortic valve stenosis in cardiogenic shock: case report

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