case_images: PMC9799189_01
case_images: (A) Electrocardiogram showing initial ischaemic changes with the patient lying supine. (B) Resolved ischaemic changes with the patient upright.
case_images: ytac465f1.jpg
case_images: PMC9799189_01_ytac465f1.jpg
case_images: ytac465-F1
case_images: ST depression in the inferolateral territory (Figure 1A). Sequential high sensitivity troponin assays increased from 15 (ng/L) to 75 (ng/L), to 332 ng/L (reference range <= 12 ng/L). Upon returning the patient to the upright position, the patient's angina dissipated within minutes with resolution of ischaemic ECG changes (Figure 1B).
case_images: Transthoracic echocardiogram pre-transcatheter aortic valve insertion aortic valve pressure gradient.
case_images: ytac465f2.jpg
case_images: PMC9799189_01_ytac465f2.jpg
case_images: ytac465-F2
case_images: The transthoracic echocardiogram (TTE) demonstrated a bicuspid aortic valve with a mean pressure gradient 94 mmHg (Figure 2), peak aortic valve velocity (Vmax) 5.9 m/s, aortic valve area of 0.7, and dimensionless performance index of 0.19.
case_images: (A) Computerized tomography coronary angiogram left anterior descending artery. (B) Computerized tomography coronary angiogram left circumflex artery. (C) Computerized tomography coronary angiogram posterior descending artery.
case_images: ytac465f3.jpg
case_images: PMC9799189_01_ytac465f3.jpg
case_images: ytac465-F3
case_images: CTCA excluded the presence of significant obstructive coronary artery disease (Figure 3A-C), confirming the diagnosis of type 2 NSTEMI in the context of critical AS; therefore, an invasive coronary angiogram was not performed. Computerized tomography with transcatheter aortic valve insertion (CT TAVI) protocol confirmed bicuspid aortic valve and that the iliofemoral vessels were suitable for transfemoral transcatheter aortic valve insertion (TAVI) (Figure 4).
case_images: Computerized tomography transcatheter aortic valve insertion protocol showing the right common femoral access site.
case_images: ytac465f4.jpg
case_images: PMC9799189_01_ytac465f4.jpg
case_images: ytac465-F4
case_images: CTCA excluded the presence of significant obstructive coronary artery disease (Figure 3A-C), confirming the diagnosis of type 2 NSTEMI in the context of critical AS; therefore, an invasive coronary angiogram was not performed. Computerized tomography with transcatheter aortic valve insertion (CT TAVI) protocol confirmed bicuspid aortic valve and that the iliofemoral vessels were suitable for transfemoral transcatheter aortic valve insertion (TAVI) (Figure 4).
case_images: Electrocardiogram 52 days post-transcatheter aortic valve insertion taken with the patient lying in the supine position that demonstrates nil new ischaemic changes. Left bundle branch block is a known post-procedure complication of transcatheter aortic valve insertion.
case_images: ytac465f5.jpg
case_images: PMC9799189_01_ytac465f5.jpg
case_images: ytac465-F5
case_images: A repeat ECG (Figure 5) did not demonstrate any new ischaemic changes.
case_images: (A) Transthoracic echocardiogram image showing the parasternal short axis view of the 26 mm Edwards SAPIEN 3 ultra bioprosthetic aortic valve in-situ. (B) Transthoracic echocardiogram post-transcatheter aortic valve insertion aortic valve pressure gradients.
case_images: ytac465f6.jpg
case_images: PMC9799189_01_ytac465f6.jpg
case_images: ytac465-F6
case_images: TTE images showing the parasternal short axis window with the TAVI valve in-situ and the post-TAVI mean pressure gradient are shown below (Figure 6AandB).