Accurate positioning of balloon-expandable valve for aortic stenosis with huge left ventricular outflow tract calcification.

An 89-year-old woman with a history of carotid artery stenting was admitted with acute heart failure and diagnosed with severe aortic stenosis. Pre-procedural computed tomography revealed huge left ventricular outflow tract (LVOT) calcification and limited vascular access due to peripheral arterial disease. In transcatheter aortic valve replacement, we selected SAPIEN3 Ultra RESILIA (Edwards Lifesciences) because system retrieval might be challenging with self-expanding valves. To minimize the risk of annular rupture and paravalvular leakage, we adopted three strategies: selection of an oversized valve to achieve supra-annular sealing, slow balloon inflation under prophylactic veno-arterial extracorporeal membrane oxygenation support, and a transcarotid approach to ensure optimal coaxial alignment. The valve was successfully deployed just above the LVOT calcification without complications. Post-procedural computed tomography confirmed appropriate positioning with adequate sealing at the superior part, in contrast to incomplete sealing at the basal edge as expected. This case demonstrates that a combination of valve oversizing, veno-arterial extracorporeal membrane oxygenation support, and a transcarotid approach can facilitate safe and accurate deployment of a balloon-expandable valve even in patients with severe LVOT calcification.