Unanticipated Pseudocoarctation Highlights the Importance of Visualizing Aortic Arch Anatomy Before Transfemoral Transcatheter Aortic Valve Implantation

A 71-year-old gentleman with background hypertension, dyslipidemia, ex-smoker, permanent atrial fibrillation, and chronic obstructive lung disease presents to our institution with exertional dyspnea (New York Heart Association class III–IV) for aortic valve replacement assessment. Cardiovascular history includes mechanical mitral valve replacement (St. Jude Medical 25 mm) alongside coronary artery bypass (venous grafts to right coronary artery and obtuse marginal) in 2004, cerebrovascular accident in 2008 with multiple transient ischemic attacks since (latest 2012), and subacute subdural hematoma requiring evacuation (2013).As part of the transcatheter aortic valve implantation work-up, he underwent a transthoracic echocardiogram, which showed a calcific, degenerative severe aortic stenosis (mean gradient, 45 mm Hg; max aortic valve velocity, 4.3 m/s; and aortic valve area, 0.8 cm2) with associated moderate regurgitation. There was preserved left ventricular function with concentric hypertrophy. The mechanical mitral valve was functioning well with a mean transvalvular gradient of 5 mm Hg and no paravalvular leaks. There were no prominent mechanical mitral valve pivot guards protruding in the left ventricular outflow tract (Figure 1A–1C). Multislice computed tomography scan revealed a tricuspid aortic valve with extensive fibrocalcific degeneration of the cusps. Annulus perimeter was 68 mm and annulus area was calculated at 3.46 cm2. Minimum ilio-femoral diameter was 5.8 cm (both sides). Cardiac computed tomography revealed patent grafts and moderate stenoses at the mid and distal segments of the left anterior descending artery. After discussion with the heart team (Euroscore II, 8.8%; Logistic Euroscore, 22.62%; STS, 7.4%; and STS MOM of 34.9%), decision was made for a transfemoral transcatheter aortic valve implantation of an Edwards …