Managing Severe Bicuspid Aortic Stenosis, Aortic Coarctation, and Impaired Left Ventricular Function

While bicuspid aortic valve and coarctation commonly coexist, diagnosis in the eighth decade of life is exceptionally rare.

A 78-year-old male patient with a history of hypertension was admitted with a 2-year history of progressive dyspnea on minimal exertion. After diagnostic workup, he was diagnosed with severe bicuspid aortic stenosis, aortic coarctation, and severely impaired left ventricle systolic function (left ventricle ejection fraction 12%). Due to high surgical risk, a stepwise percutaneous strategy was adopted, starting with coarctation stenting which improved the left ventricle ejection fraction to 32%, allowing for successful transcatheter aortic valve replacement using a snare-assisted technique.

Treating the coarctation first facilitated valve delivery and reduced afterload, improving systolic function, and ultimately reducing the need for ventricular support during transcatheter aortic valve replacement.

A stepwise approach is crucial in managing high-risk patients with complex structural heart disease, demonstrating the importance of meticulous preprocedural planning.