case_images: PMC9727381_01
case_images: (A) Preprocedural AV CWD recording from Apical 5 chamber view, with high maximum velocity = 5.1 m/s, mean PG = 66 mmHg (B) inter commissural distance (4-5 mm) above the annular level = 35 mm, (C) AV significant calcification at the raphe level (D) annulus measurement showing small annular calcific nodule, and (E) illustration of the Myval design showing the dense (dark blue arrows), light bands (light blue arrows) and deployment within the annular plane (red dotted line) to obtain a proper position and implantation depth. (F) Implantation depth (G,H) pre and postprocedural ECG without changes. AV, Aortic valve, BAV, Bicuspid Aortic Valve, CCTA, Cardiac Computed Tomography, CWD, continuous wave Doppler, ECG, Electrocardiogram, PG, Pressure Gradient.
case_images: fcvm-09-1045280-g001.jpg
case_images: PMC9727381_01_fcvm-09-1045280-g001.jpg
case_images: F1
case_images: The left and right coronary heights were 15 and 25 mm, respectively (Figure 1). The deployment within the annulus was performed in the tri-coplanar view (LAO15/CRA3), guided by the dense and light marking bands of the crimped device, a feature characteristic of the Myval (Figure 1E and Supplementary Video 1), with temporary pacing over the LV guidewire. No intraprocedural complications were reported, and the post-procedural ECG showed no new conduction disturbance (Figures 1G,H).
case_images: PMC9727381_02
case_images: (A) Preprocedural AV continuous wave Doppler with high maximum velocity, (B) preprocedural MSCT showing BAV with partially fused L-R raphe and significant AV calcifications, (C) annulus measurement showing large annulus with large annular calcific nodule, (D) LVOT profile view (no calcification) and ICD 4-5 mm above the annulus = 35 mm, (E) Myval-XL 32 mm deployment, (F) preprocedural ECG, and (G) postprocedural ECG without changes.
case_images: fcvm-09-1045280-g002.jpg
case_images: PMC9727381_02_fcvm-09-1045280-g002.jpg
case_images: F2
case_images: The measurements documented a large annulus with a perimeter of 101 mm, a perimeter-derived diameter of 31.5 mm, an area of 774 mm2, an ICD of 35 mm, and wide sinuses (Figure 2). A 32 mm Myval-XL was selected for TF-TAVR with the risk of annular injury due to the annular calcium chunk (not extending to the LVOT). Balloon pre-dilatation was performed using a Sapien-25 mm balloon. The device deployment was performed using the Navigator delivery system in the tri-coplanar view (RAO4/CRA5) with pacing over the LV guidewire. The post-procedural ECG showed no alteration of the conduction (Figures 2F,G).
case_images: PMC9727381_03
case_images: (A) CCTA Annulus measurements with a very large area, (B) wide sinuses, (C) all calcifications (3D Hockey Puck-MIP view), (D) ascending aorta diameters, (E) angiographic aortic angulation showed horizontal aorta, and (F) aortic valve calcifications (Agatston and volume mm3) measured from non-contrast CT scan.
case_images: fcvm-09-1045280-g003.jpg
case_images: PMC9727381_03_fcvm-09-1045280-g003.jpg
case_images: F3
case_images: TTE confirmed severe AS with an EOA of 0.8 cm2 and preserved LV-EF. A preprocedural-CCTA disclosed a severely calcified BAV Sievers type 1-a, with calcified raphe and an Agatston calcium score of 6132 and calcium volume of 4757 mm3 from a non-contrast CT-scan (Figure 3 and Supplementary Video 3).