Navigating Complexity: Transcatheter Aortic Valve Replacement (TAVR) in an Elderly Patient With Critical Aortic Stenosis and Severe Annular Calcification.

We present the case of a 93-year-old female patient with critical calcific aortic stenosis, severe annular and left ventricular outflow tract (LVOT) calcification, and reduced ejection fraction who underwent transcatheter aortic valve replacement (TAVR) with a 23-mm Edwards Sapien 3 Ultra valve. Post-procedure, she experienced a mild to moderate paravalvular leak (PVL) with an improvement in ejection fraction. At the one-month follow-up, worsening dyspnea and moderate to severe PVL were noted. Percutaneous PVL closure was successfully performed using an 8-mm Amplatzer Vascular Plug II, effectively reducing the leak to a trace. The patient was discharged the following day and remains independent with minimal symptoms at eight months. This case highlights the challenges of managing severe annular calcification during TAVR and the utility of PVL closure to improve clinical outcomes.