Transapical aortic valve implantation in a patient with increased diameter of the aortic annulus and extensive calcification

Methods The patient is a 66y old male referred for evaluation of aortic stenosis, and presenting with fatigue, class III heart failure, hypertension, diabetes, 1st degree AV block, LBBB, previous stroke and moderate CKD. EuroSCORE I was 5.35% and EuroSCORE II was 1.98%. Echocardiography confirmed severe aortic stenosis, with an annulus 0.8 cm2, mean and peak systolic gradient 54 and 86 mmHg, and ejection fraction 59%. CT angiography showed a mean annulus diameter 28.4mm, sinotubular region 33.5mm, ascending aorta 41.1mm and volume of calcified region 892mm3. Given the low risk score, conventional surgery was indicated, but the patient rejected it and accepted only TAVI. Even the largest prosthesis available would require an aortic annulus diameter less than 26mm, versus 28,4mm from our patient. Despite this apparent mismatch and taking into consideration the extensive calcification and the patient’s condition, the heart team, after exposing the risks to the patient and his family, indicated the transapical procedure.