High Implantation Technique During CoreValve Replacement in a High-Risk Aortic Stenosis Patient with a Sigmoid Left Ventricular Hypertrophy and a Large Aortic Annulus.

The appropriate size, accurate alignment and correct positioning of transcatheter aortic valves (TAVIs) at the point of deployment are emphasized as key factors in placement and fixation of the devices. Presence of a sigmoid left ventricular septum in the patient is one of the important limitations of TAVIs, especially with the Edwards-Sapien Valve (ESV), due to the risk of aortic embolization of the prosthesis. In cases of a pronounced sigmoid septum, transapical implantation of the ESV or the usage of a Medtronic CoreValve (MCV) is generally recommended. However, severe left ventricular hypertrophy and sigmoid septum are also risk factors for the development of conduction disturbances with the usage of MCV. The depth of implantation of MCV within the left ventricular outflow tract and larger or significantly oversized prostheses have also been reported as important predictors of permanent pacemaker (PPM) requirement after MCV implantation. Thus, recent reports indicate that there may be less need for a PPM if a high implantation technique is used to place the MCV at a short implantation depth. In this report, we present the high implantation technique under rapid pacing during transcatheter aortic MCV implantation in a surgically high-risk aortic stenosis patient with sigmoid left ventricular hypertrophy and a large aortic annulus.