2019 Scientific Sessions

Title Severe Aortic Valve Stenosis with a Large Sinus of Valsalva Aneurysm: Navigating the Risk of Transcatheter Aortic Valve Replacement Introduction Transcatheter aortic valve replacement (TAVR) is recommended in patients with severe symptomatic aortic stenosis (AS) who are intermediate or high-risk for surgical aortic valve replacement. The presence of a concomitant sinus of Valsalva aneurysm (SVA) poses an increased risk for complications. As these anomalies are rare, TAVR remains understudied and the optimal type of valve, perioperative planning and deployment techniques are unknown. We present a case integrating 3-dimensional computed tomographic (CT) images during TAVR workup in a patient with a large SVA and severe symptomatic AS to optimize procedural outcomes and minimize risk. Clinical Case A 95 year old man with a history of hypertension, heart failure, and AS presented with exertional dyspnea. His echocardiogram showed ejection fraction (EF) of 25%, which was previously normal. AVA was 0.58 cm² and mean gradient was 35 mmHg. His estimated STS mortality risk was 8.3% and he was deemed inoperable by two cardiothoracic surgeons. During TAVR evaluation, a concomitant SVA was discovered. Detailed 3D CT images were obtained to better visualize the anatomy of the aortic root. The SVA was 2.3 x 1.2 x 2.2 cm in size, located below the right and non-coronary cusps, between the aortic root, interatrial septum and extending to the membranous interventricular septum. Aortic annular dimensions based on CT TAVR protocol were calculated with bi-plane diameter of 26.9 x 28.6 mm, annulus area of 567 mm² and perimeter of 91 mm. A Medtronic self-expanding Evolut R CoreValve 34 mm was chosen. The valve was positioned at a depth of 8 mm on the non-coronary cusp in order to cover the aneurysm. Decreased filling of the aneurysm was noted immediately after the aortic valve replacement in the angiogram, which was also noted in the follow-up CT imaging. A month after the procedure, patient had significant improvement in his symptoms with an EF of 40-45%. Discussion Sinus of Valsalva aneurysm is a pseudoaneurysm. Though mostly asymptomatic, complications such as rupture, thrombosis, and worsening aortic regurgitation can occur. While the presence of pseudoaneurysm is not an absolute contraindication for TAVR, it can increase the risk of annulus rupture and complicate valve positioning. 3D CT imaging, which utilizes ECG-gated synchronization, offers an accurate measurement of the aortic annulus in the systolic phase. This aids in choosing the appropriate valve and size to mitigate complications like valve migration, paravalvular leak, and aortic regurgitation. A self-expanding valve offers passive radial force, which carries a lower risk of rupture than balloon expansion. With this kind of valve, deep positioning is possible when pseudoaneurysm is encountered. In conclusion, TAVR is feasible in patients with large pseudoaneurysms by utilizing CT imaging, choosing an appropriate valve, and having a well-planned deployment strategy.