Modified balloon-assisted shoehorn technique for transcatheter aortic valve implantation in functionally horizontal anatomy: a case report.

BACKGROUND

Transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve (BAV) poses unique challenges. We report a case in which an apparently benign anatomy resulted in failure of conventional delivery strategies and required a novel balloon-assisted bailout technique.

CASE SUMMARY: A 59-year-old man with a background history of liver cirrhosis presented with severe aortic stenosis due to type 1 BAV. The patient was in Child-Pugh class A with model for end-stage liver disease (MELD) score of 14; hence, he was planned for TAVI in view of high surgical risk. Pre-procedural computed tomography showed a favourable left ventricular (LV)-aortic angle, but the fused non-coronary and right-coronary cusp behaved like functional horizontal anatomy. Various previously described wire and balloon-assisted techniques failed to deliver the valve. A novel balloon-assisted modified 'shoe-horn' technique, by inflating a 16 mm balloon in non-coronary sinus, altered the delivery trajectory and enabled successful valve delivery.

DISCUSSION: BAV with right non-coronary cusps fusion may behave like horizontal anatomy, despite favourable LV-aortic angle. A modified balloon-assisted shoe-horn technique can facilitate valve delivery when conventional methods fail. This case highlights an under-recognized mechanism of valve delivery failure in BAV and emphasizes the importance of preparedness for advanced bailout strategies.