“Silent” Acute Native Valve Leaflet Avulsion during Transcatheter Aortic Valve Replacement

An 86 year old female was referred to our facility for management of severe symptomatic aortic stenosis manifested as dyspnea at rest and syncope. Our multidisciplinary heart valve team deemed her to be high risk for surgical AVR due to NYHA functional class IV congestive heart failure, severe right ventricular dysfunction, pulmonary hypertension, chronic lung disease and diabetes mellitus. Transesophageal echocardiography (TEE) showed a trileaflet aortic valve with moderate to severe concentric leaflet calcification. The valve area was 0.4 cm2, with peak and mean gradients of 68 and 44 mm Hg respectively. The left ventricular ejection fraction was 35%. The patient’s STS (Society of Thoracic Surgeons) risk of mortality score was 11 percent. On multi-detector computed tomography, the average basal ring diameter was determined to be 21 mm. The transfemoral route was chosen because non-invasive assessment demonstrated suitable access site and vascular anatomy.