Objective: Although most transcatheter aortic valve replacement (TAVR) procedures for symptomatic severe aortic valve stenosis (AS) can be performed successfully, there are some challenging cases with several specific anatomical characteristics, such as a horizontal aorta, aortic dilatation, and bicuspid aortic valve. A short, straight ascending aorta length (SAAL) can cause the transcatheter heart valve (THV) device to lack the distance required to orient in the direction of the aortic annulus, leading to failure to cross the aortic valve. This study aimed to examine the characteristics of SAAL and its association with the difficulty of THV device crossing.

Methods: This is a retrospective study that included 307 consecutive patients with symptomatic severe AS who underwent TAVR at our hospital from October 2018 through July 2024. Patients were divided into two groups based on SAAL: the short SAAL group (<42.8 mm, n = 50) and the long SAAL group (≥42.8 mm, n = 257). The cutoff value was determined using receiver-operating characteristic (ROC) curve analysis and the Youden Index (area under the curve [AUC] = 0.75; sensitivity = 0.85; specificity = 0.71). The primary endpoint was difficulty in THV device crossing on the first attempt using the standard technique, without the aid of assistive devices such as a snare system.

Results: In the overall population, the rate of difficulty in THV device crossing through the aortic valve was 2.2%. The short SAAL group had a significantly higher rate of crossing difficulty compared to the long SAAL group (5 cases, 10.0% vs. 2 cases, 0.7%; p = 0.002). In a univariate logistic regression analysis, SAAL was significantly associated with difficult THV device crossing (per 1-mm increase: odds ratio [OR] = 0.86, 95% confidence interval [CI]: 0.77–0.96, p = 0.009; SAAL <42.8 mm: OR = 14.37, 95% CI: 2.70–76.42, p = 0.002). ROC analysis showed that SAAL was more predictive of difficulty in THV device crossing compared to other conventional anatomical factors (per 1-mm increase: AUC = 0.75, 95% CI 0.54–0.97, p = 0.019; SAAL <42.8 mm: AUC = 0.78, 95% CI 0.58–0.98, p = 0.010).

Conclusion: In patients with SAAL <42.8 mm, THV device crossing is more challenging during TAVR. Preoperative SAAL measurement, in addition to conventional anatomical factors, may provide valuable procedural guidance in determining whether an assistive device is needed, thereby helping to prevent severe complications.

Objective: Balloon aortic valvuloplasty (BAV) is frequently performed during transcatheter aortic valve implantation (TAVI). However, there are currently limited data regarding the benefits and drawbacks of BAV with self-expanding valves. This study retrospectively compares valve function with and without BAV during TAVI using self-expanding valves.

Methods: From November 2015 to December 2023, our hospital conducted 363 consecutive TAVI procedures using self-expanding valves (CoreValve/Evolut series; Medtronic, Minneapolis, MN, USA). Excluding five perioperative deaths, we analyzed 358 cases: 147 without BAV and 211 with at least one BAV during the procedure. The cohort's mean age was 84.9 years, with 67% female patients. The criterion for performing BAV before TAVI (pre-BAV) was a preoperative mean pressure gradient of 60 mmHg or higher, and the criteria for performing BAV after TAVI (post-BAV) were: if moderate or severe paravalvular leakage was observed after valve deployment; if the post-TAVI mean pressure gradient was 15 mmHg or higher; and if frame underexpansion of the TAVI valve was noted. We assessed pre- and postoperative echocardiography, the incidence of symptomatic cerebral infarction within 30 days after TAVI, and 1-year mortality.

Results: Preoperative echocardiography revealed that the non-BAV group had a significantly larger valve area (0.71 ± 0.16 vs. 0.66 ± 0.19 cm², p < 0.01) and a lower mean pressure gradient (40.1 ± 9.3 vs. 58.2 ± 18.1 mmHg, p < 0.001). Postprocedural echocardiography demonstrated comparable valve areas in both groups (1.77 ± 0.39 vs. 1.78 ± 0.39 cm², p = 0.81) and single-digit mean pressure gradients (6.75 ± 2.9 mmHg vs. 7.66 ± 3.4 mmHg, p < 0.01). The incidence of symptomatic cerebral infarction within 30 days was lower in the non-BAV group (2.7% vs. 7.6%, p = 0.048), while the 1-year mortality rate was similar between groups (6.8% vs. 7.6%, p = 0.91, log-rank).

Conclusion: In selected cases of TAVI with a self-expanding bioprosthetic valve, the omission of BAV did not appear to adversely affect postoperative valve function. Moreover, avoiding BAV may help reduce the risk of potential adverse events, such as cerebral infarction.

Objective: This prospective single-center study aimed to evaluate platelet function and coagulation ability in patients undergoing thromboelastography (TEG) during the perioperative period of transcatheter aortic valve implantation (TAVI).

Methods: Thirty patients with severe aortic valve stenosis who underwent transfemoral TAVI were prospectively recruited. Samples were obtained at three time points: T0, postanesthesia induction (preheparin); T1, post-protamine administration (1 mg/100 IU heparin); and T2, the day after surgery. At each time point, blood samples were examined using a TEG6s analyzer and standard laboratory tests (hemoglobin level, platelet count, prothrombin time, activated partial thromboplastin time, and fibrinogen level). We compared the changes in the reaction time (R), kinetics (K), angle, maximum amplitude (MA), and LY30 among the three time points for citrated kaolin (CK), citrated kaolin with heparinase (CKH), citrated rapid thromboelastogram (CRT), and citrated functional fibrinogen (CFF).

Results: No difference was observed in the MA among CK, CKH, CRT, and CFF. K, which indicates the rate of clot formation, and R, which indicates the clotting time, increased at T1 and decreased the day after surgery (T2). None of the patients experienced perioperative bleeding or embolic complications.

Conclusion: The clotting time decreased from the day after surgery. These results may be helpful in determining the appropriate antithrombotic therapy after TAVI.

Trial registration: The trial was registered on April 28, 2023, at UMIN (UMIN00005094; https://center6.umin.ac.jp/cgi-open-bin/ctr/ctr_view.cgi?recptno=R000058000).

Objective: Transcatheter aortic valve implantation (TAVI) has become the standard treatment for older or high-risk surgical candidates with severe symptomatic aortic stenosis. However, reports on the mid-term outcomes of TAVI in patients with small annuli are limited. This study aimed to comprehensively evaluate the procedural success, hemodynamic performance, and midterm outcomes of TAVI using balloon-expandable transcatheter heart valves (BEVs) and self-expandable transcatheter heart valves (SEVs) in this population.

Methods: This single-center retrospective cohort study included 81 patients with an aortic valve annulus area <350 mm² who underwent TAVI between July 2016 and March 2024. The patients were divided into BEV (N = 58) and SEV (N = 23) groups. The primary endpoint was all-cause mortality, and the secondary endpoints were adverse cardiovascular events and hemodynamic valve performance. Additionally, we compared clinical outcomes between patients with or without moderate or severe prosthesis–patient mismatch (PPM).

Results: Baseline characteristics showed that the SEV group was significantly shorter, lighter, and had a smaller body surface area (P <0.05). The procedural success rates were comparable between groups. The SEV group demonstrated superior hemodynamic performance, with larger indexed effective orifice areas (P <0.001) and lower mean pressure gradients (P <0.001). However, the BEV group had lower rates of paravalvular leakage ≥moderate and permanent pacemaker implantation. Moderate PPM was more frequent in the BEV group (P = 0.054), but no significant differences in all-cause mortality (P = 0.25), cardiovascular events (P = 0.12), or heart failure hospitalization (P = 0.28) were observed between patients with or without moderate or severe PPM. At five years, no significant differences in all-cause mortality and cardiovascular event-free survival were observed.

Conclusion: Both the BEV and SEV groups achieved favorable midterm outcomes in patients with small annuli. Although the SEV group showed superior hemodynamic performance, the BEV group showed fewer complications, such as paravalvular leakage. Despite a higher incidence of moderate PPM in the BEV group, no significant impact on clinical outcomes was observed. Individualized valve selection and long-term follow-up remain crucial for optimizing outcomes in this challenging population.

Objective: A few cases of simultaneous transcatheter aortic valve implantation (TAVI) and endovascular aortic repair (EVAR) have been reported; however, simultaneous TAVI and thoracic EVAR (TEVAR) are rare. We aimed to report the successful treatment of a case of severe aortic valve stenosis (AS) concomitant with a giant thoracic aortic aneurysm (TAA), in which TEVAR preceded TAVI.

Case Presentation: An 81-year-old patient was referred to our hospital for the treatment of severe AS and a large dissecting TAA. The TAA abruptly enlarged in a short time and showed plaque-rich atheroma; therefore, passing the TAVI device through the TAA was a concern. Moreover, hemodynamic instability because of severe AS during TEVAR under general anesthesia was a concern. After discussion with the multidisciplinary team, we planned simultaneous surgery with TAVI after TEVAR in this case. Before surgery, extracorporeal membrane oxygenation (ECMO) support was prepared via the left femoral artery and vein, and TEVAR was performed through the right femoral artery. TAVI was performed after the sheath was changed. Although passing the TAVI device through the stent graft was slightly difficult, it was possible with guidewire control.

Conclusion: TAVI was successfully performed after TEVAR in a patient with severe AS and a giant thoracic aneurysm. We were able to prevent critical aortic-related events because TEVAR was performed beforehand.

Purpose: We present a case of an underweight elderly woman with severe aortic stenosis and mitral regurgitation successfully treated with transcatheter aortic valve replacement (TAVR) through retroperitoneal approach and staged mitral valve transcatheter edge-to-edge repairment (M-TEER).

Case Presentation: The patient was a thin, 79-year-old woman who presented to our hospital with New York Heart Association functional classification (NYHA) class III heart failure symptoms. Her transthoracic echocardiography showed severe aortic stenosis (AS) and severe mitral regurgitation (MR). Her transesophageal echocardiography showed an MR jet emerging from the A2-P2 junction. First, our heart team planned to implement TAVR. Since her MR was a mixed type (atrial and degenerative) MR, there was a possibility that it could be treated with TAVR solely. However, in case MR remained, there was an indication for M-TEER, and her mitral valve configuration was feasible for the procedure. Weighing the risk of left ventricular systolic dysfunction and arrhythmia due to increased afterload, we decided to perform TAVR first and to proceed to M-TEER only if severe MR and heart failure symptoms persisted. Since the transfemoral approach was difficult due to her thin common femoral arteries, retroperitoneal approach was employed in TAVR. One month after dischawrge, she still had NYHA II heart failure symptoms, and transthoracic echocardiography showed severe MR, so we decided to perform M-TEER. Two months after TAVR, M-TEER was performed and Mitraclip G4 XTW (Abbott, Abbott Park, IL, USA) was implanted in the A2-P2 region. The patient’s postoperative course was favorable, and her subjective symptoms improved to NYHA I.

Conclusion: We experienced a case of severe aortic stenosis and mitral regurgitation successfully treated with TAVR through retroperitoneal approach and staged M-TEER.

Purpose: Transcatheter aortic valve implantation (TAVI) is the mainstay of treatment for severe aortic stenosis and improves outcomes. However, complications of TAVI can lead to hemodynamic compromise. Aortic regurgitation (AR) is a frequent and mostly paravalvular complication; however, transvalvular leakage is rare because of stuck leaflets.

Case Presentation: A 90-year-old woman was admitted for acute decompensated heart failure; she was diagnosed with very severe aortic valve stenosis. The patient underwent transfemoral TAVI with a balloon-expandable valve. After valve deployment, moderate paravalvular leak was observed. Subsequently, she underwent post-dilatation; rapidly worsening hypotension was observed immediately. This condition necessitated cardiopulmonary resuscitation because of massive transvalvular AR caused by a stuck leaflet. After placing an emergency valve in valve, hemodynamic parameters improved rapidly.

Conclusion: This case describes massive AR caused by a stuck leaflet after post-dilatation during TAVI using a balloon-expandable valve.

Objective: Balloon rupture during transcatheter aortic valve implantation (TAVI) can be a challenging complication to manage, especially with alternative access routes. We report a case of a successful bailout after a balloon rupture during trans-subclavian TAVI.

Case Presentation: An 83-year-old woman was scheduled to receive TAVI. Peripheral access was poor, so we planned for a trans-subclavian approach. The patient has low left ventricular function, and an arterial cannula for percutaneous cardio-pulmonary support was inserted from the left subclavian artery (SCA), and then, it was decided to perform TAVI through the right SCA. However, during the valve alignment process, the axis of the sheath and the axis of the valve did not align properly, and the balloon ruptured, making both deployment and retrieval impossible. Under median sternotomy, we successfully retrieved the valve under a simple clamp of the brachiocephalic artery. Trans-aortic TAVI was followed successfully and the patient is still in good condition.

Conclusion: Balloon rupture during TAVI via trans-subclavian access can be successfully managed. This case highlights the importance of having bailout strategies for complications during TAVI procedures.

Objective: We report a case of microscopic pulmonary arteriovenous malformations (PAVMs) diagnosed by selective microbubble testing from the pulmonary artery.

Case Presentations: A 56-year-old woman simultaneously experienced multiple cerebral infarctions, acute right pulmonary artery thromboembolism, and deep vein thrombosis at 44 years old. Conventional, non-selective microbubble testing using transesophageal echocardiography (TEE) was positive. She began warfarin administration, which was discontinued after 6 months due to no thrombosis recurrence and no congenital thrombosis predisposition. Later, preoperative TEE did not confirm patency of the foramen ovale, but non-selective microbubble testing was again positive. Although a clear patent foramen ovale (PFO) could not be identified, the possibility of a PFO with an extremely small shunt tract could not be ruled out and required further examination. Attempts to pass the foramen ovale with a multipurpose catheter under TEE guidance were unsuccessful. Next, we inserted a catheter into the pulmonary artery for selective microbubble testing. We observed bubble inflow from the right pulmonary artery to the right upper pulmonary vein, which enabled a diagnosis of microscopic PAVMs. Although these might constitute a contributing factor to paradoxical embolism, the shunt volume was thought to be small. We opted against shunt embolization, instead prescribing edoxaban to prevent thrombosis.

Conclusion: Selective microbubble testing from the pulmonary artery could detect microscopic PAVMs and was effective for differentiation from a PFO.