Tunnel-Like Calcification on a Coronary Leaflet　― A Warning Sign in Transcatheter Aortic Valve Replacement ―

An 86-year-old man was admitted with acute heart failure due to severe aortic valve stenosis with impaired left ventricular (LV) contraction. Semi-urgent transcatheter aortic valve replacement (TAVR) was performed because conservative treatment had been ineffective. During TAVR, transesophageal echocardiography revealed that the wire was passing between 2 separate calcifications on the left coronary cusp into the LV (Figure A). Balloon aortic valvuloplasty was attempted with an 18-mm INOUE Balloon^TM (Toray Industries Inc.), but the balloon did not expand well after significant resistance during its advancement, suggesting a potential contribution to complications such as balloon rupture and subsequent ventricular or aortic injury (Figure B; Supplementary Movie 1).¹ Therefore, the balloon was not fully inflated, and the wire was reinserted through the center of the aortic valve (Figure C). After full balloon expansion was confirmed (Figure D), a 26-mm Evolut FX valve (Medtronic) was successfully implanted. Re-evaluation of the preoperative computed tomography (CT), suggested the wire had passed through a tunnel-like calcification (Figure E,F; Supplementary Movie 2).

Figure.

(A,B) Initial insertion of the wire and (C,D) reinserted wire. Red arrowheads indicate wire. Yellow asterisks indicate calcification. (E) Cross-sectional view and (F) 3-dimensional reconstructed image. Red arrowheads indicate the tunnel-like structure and yellow indicates calcification. NCC, noncoronary cusp; RCC, right coronary cusp.

Evaluating the degree and distribution of aortic valve leaflet calcification with preprocedural CT is recommended to mitigate the risk of complications. However, little attention has been paid to configurations such as the tunnel-like calcification in this case, which highlights the importance of preoperative evaluation of the morphological features of aortic valve calcification for safe performance of TAVR.

Disclosures

H.O. is a member of Circulation Journal’s Editorial Team.

Acknowledgments / Data Availability

None.

Supplementary Files

Supplementary Movie 1. Angiography during balloon aortic valvuloplasty with INOUE balloon.

Supplementary Movie 2. Three-dimensional reconstructed CT images.

Please find supplementary file(s);

https://doi.org/10.1253/circj.CJ-25-0048

Reference

• 1.   Wu X, Wu T, Wang R, Elkoumy A, Wu D, Soliman O, et al. Balloon rupture during pre-dilation for transcatheter aortic valve replacement in patients with a bicuspid aortic valve: Classification, treatment strategies, and prevention. Cardiovasc Innovations Appl (CVIA) 2023, doi:10.15212/CVIA.2023.0063.