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

objectivesCalcific 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. KEY STEPS: 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. POTENTIAL PITFALLS: 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. TAKE-HOME MESSAGES: 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.