CASE DESCRIPTION:
An 89-year-old man with a history of hypertension and type 2 diabetes mellitus presented with shortness of breath and bilateral legs edema 2 weeks prior to evaluation. Severe symptomatic aortic stenosis was confirmed in other hospital, and the patient was referred to our institution for TAVR. Chest X-ray revealed prominent lung edema with bilateral pleural effusion. Transthoracic echocardiography demonstrated poor left ventricular systolic function (left ventricular ejection fraction: 36.4 %) and tricuspid configuration aortic valve with severe stenosis (peak velocity: 4.2 m/s; mean transvalvular pressure gradient: 41 mmHg; estimated valve area: 0.53 cm2). He was dependent on intravenous infusion of inotropic agents, and was deemed at high risk for surgical aortic valve replacement with predicted surgical mortality of 8.234 % by STS-PROM (Society of Thoracic Surgeons-Predicted Risk of Mortality) and 17.37% by EuroSCORE (European System for Cardiac Operative Risk Evaluation-II). Multidetector computed tomography (CT) showed a huge annulus measuring 37.9 × 27.8 mm in diameter and an area of 831.8 mm2 (Figure 1). The measured annulus size exceeds the upper limit of both the commercially available self-expanding and balloon-expanding THV in our institution. In view of the patients age and high surgical risk, the decision was made by the heart team to proceed with TAVR by over-expansion of 29 mm SAPIEN 3 THV.
The procedure was performed under conscious sedation and right femoral access. Temporary pacemaker was placed in right ventricle via internal jugular vein. A 29 mm Edwards SAPIEN S3 THV was inserted and expanded by overfilling of the deployment balloon with 4 ml of additional volume under rapid pacing. The post-TAVR aortography revealed a well-positioned THV with mild paravalvular regurgitation (Figure 2).  The maximal diameter of post-deployment THV was 32.23 mm by quantitative fluoroscopy analysis (Figure 3). The procedure was uncomplicated and there was no new conduction disturbance requiring permanent pacemaker. The patient was discharged 6 days after TAVR. The 1-month follow-up transthoracic echocardiography showed well-functioning THV (peak velocity= 1.9 m/s; mean transvalvular gradient= 7.9 mmHg; estimated valve area= 2.1 cm2) with a mild paravalvular leakage (Figure 4).