Valve Pop-Up and Infolding in Transcatheter Aortic Valve Replacement for a Heavily Calcified Bicuspid Valve.

BACKGROUND

Transcatheter aortic valve replacement (TAVR) in bicuspid aortic valve (BAV) anatomy remains challenging, especially in the presence of heavy calcification.

CASE SUMMARY: A patient with severe aortic stenosis and a heavily calcified type 1 BAV with a calcified raphe underwent transfemoral TAVR with a 29-mm self-expanding Evolut FX + valve. At final release, delayed prosthesis pop-up toward the ascending aorta occurred. Recapture was unexpectedly successful, but redeployment from a deeper position led to frame infolding. The prosthesis was retrieved, and definitive bailout was achieved with a balloon-expandable 29-mm SAPIEN 3 Ultra RESILIA valve and postdilation, resulting in mild residual paravalvular leakage.

DISCUSSION: Severe calcification in BAV anatomy can complicate TAVR and may be associated with underexpansion, delayed migration, and infolding after resheathing or redeployment.

TAKE-HOME MESSAGES: Stability checks near final release are essential in calcified BAV anatomy. If infolding is suspected, device-specific instructions should guide prompt definitive management.