TAVR Procedural Planning for Patients With Supra-Annular and Sinotubular Junction Constriction

Calcific constriction of the supra-annular aorta and sinotubular junction (STJ) can significantly impair transcatheter aortic valve replacement (TAVR), leading to suboptimal valve expansion and leaflet dysfunction. We describe a case of severe STJ constraint in which bench testing demonstrated constrained expansion dynamics and informed a tailored transcatheter strategy resulting in successful valve deployment with favorable hemodynamics.

1) Recognition of severe STJ-annulus mismatch and high-risk anatomy on preprocedural computed tomography; 2) bench testing demonstrating constrained expansion and leaflet "cogwheeling"; 3) selection of an appropriate transcatheter valve platform based on anatomical considerations; 4) careful balloon predilation and iterative deployment with optimized (relatively infra-annular) positioning; and 5) use of meticulous procedural techniques to minimize embolic and conduction risk.

Failure to recognize STJ constraint may result in asymmetric expansion, leaflet dysfunction, sinus sequestration, paravalvular regurgitation, coronary obstruction, or annular injury. Balloon-expandable valves may carry increased risk in rigid anatomies due to abrupt radial force transmission.

Constricted supra-annular aorta and STJ represent a significant challenge in transcatheter aortic valve replacement. Careful 3-dimensional planning, appropriate valve selection, and tailored deployment strategies are essential to optimize procedural and hemodynamic outcomes.