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case_images: Transthoracic echocardiography demonstrating severe aortic regurgitation. (A) Parasternal long axis (vena contracta 1 cm); (B) continuous wave (CW) Doppler through the aortic valve in the apical 5-chamber view.
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case_images: In 2023, she re-presented with dyspnoea and TTE demonstrated severe AR with poor LV function (LVEF 15%) (Figure 1).
case_images: Computed tomography demonstrating absence of aortic valve calcification (A and B). (C) Neo-annulus measured 660 mm2; (D) left main coronary height 7.1 mm.
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case_images: The neo-annulus measured 660 mm2 and left coronary height was low at 7.1 mm (Figure 2).
case_images: Fluoroscopy demonstrating a lack of balloon waisting (A), positioning (B), and deployment (C and D) of the transcatheter heart valve (THV) below the left main coronary artery.
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case_images: The THV was then positioned below the LMCA in order to preserve unrestricted coronary access and facilitate future redo TAVR (Figure 3).
case_images: (A) Post-transcatheter aortic valve replacement aortography showed no aortic regurgitation: (B) continuous wave Doppler through the aortic valve; (C) colour Doppler in the short axis view; (D) computed tomography at follow-up showed preservation of left main coronary access.
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case_images: AR (Figure 4) and only a mild waist of the THV. CT imaging at 3 months showed no THV migration and a position below the level of the left coronary ostium (Figure 4).
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case_images: Transoesophageal echocardiography (long axis view) demonstrating recurrence of aortic regurgitation (AR) after valve sparing aortic root replacement due to prolapse of the right coronary cusp (arrow:A) and with colour Doppler (B) showing an eccentric jet of severe AR (vena contracta 0.7 cm).
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case_images: Transoesophageal echocardiography revealed severe AR due to prolapse of the right coronary cusp (Figure 5).
case_images: Computed tomography scan showing absence of leaflet calcification (A), a perimeter of 8.13 cm (B), right coronary artery height of 18.8 mm (C), and left main coronary height of 18.2 mm (D).
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case_images: TAVR. The neo-annulus measured 525 mm2, LMCA height 18.2 mm, and RCA height 18.8 mm (Figure 6). The sinus of valsalva and STJ were narrow (28 and 25 mm) and there was a 'kink' at the STJ (Figure 6D). STJ height was 21 mm.
case_images: A 25 mm sizing balloon anchored (A). The 26 mm Sapien transcatheter heart valve (THV) was positioned below the left main coronary artery and deployed with 4 cc overfill (B). The mild waist of the THV frame indicates good anchoring (C) with no residual aortic regurgitation on aortography (D).
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case_images: THV was positioned below the LMCA both to preserve immediate and future coronary access, should redo TAVR be required (Figure 7). There was no evidence of AR on aortography or echocardiography post-TAVR.
case_images: Transthoracic echocardiography 4 months post-transcatheter heart valve (THV) implantation: no residual aortic regurgitation by colour flow Doppler (A) and satisfactory transvalvular gradients (B); (C and D) CT scan demonstrating no migration of the THV and preservation of coronary access (left main coronary artery panel C, right coronary artery panel D).
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case_images: CT imaging at 8 months showed no migration of the THV and preserved coronary access (Figure 8).