Intravascular Lithotripsy-Enabled Transcatheter Aortic Valve Replacement in Heavily Calcified Bicuspid Aortic Valve

Transcatheter aortic valve replacement (TAVR) in bicuspid aortic valves (BAVs), especially with severe calcification, presents challenges including prosthesis underexpansion and paravalvular leak.

We present a critically unwell 70-year-old man with severe aortic stenosis in a heavily calcified Sievers-0 BAV, complicated by heart failure and chronic kidney disease. Intravascular lithotripsy (IVL) was used for calcium modification, followed by balloon valvuloplasty and deployment of a 26-mm Evolut PRO+ valve. The patient had excellent clinical recovery, with no paravalvular leak and improved ventricular function.

This case highlights the novel use of IVL to facilitate TAVR in a complex calcified BAV anatomy. IVL enables controlled calcium fracture and improves compliance, optimizing prosthesis expansion and reducing complications. However, the lack of dedicated valvular IVL platforms remains a current limitation.

IVL may enhance lesion preparation in heavily calcified BAVs undergoing TAVR. Dedicated IVL devices for structural interventions are an emerging need.