Trans-catheter aortic valve implantation in a patient with membranous ventricular septal defect, sub-aortic band, and double-chambered right ventricle: a case report.

Background: We report a rare case of trans-catheter aortic valve implantation (TAVI) in an elderly male with membranous ventricular septal defect (VSD), sub-aortic band, and severe aortic stenosis (AS). We discuss the safety and efficacy of the technique.

Case Summary: An 86-year-old male was admitted to our hospital with congestive heart failure due to low-flow low-gradient severe AS, a membranous VSD, a sub-aortic band, and a double-chambered right ventricle (RV). The patient was not deemed to be a surgical candidate because of advanced age and frailty even though surgical aortic valve replacement, VSD closure, sub-aortic band resection, and myectomy of RV would be considered as definitive treatment. Instead, we performed TAVI and VSD orifice closure using the skirt part of the self-expanding valve (26 mm Evolut Pro Plus™) because VSD occluder is not approved and thus not available in our country. The trans-catheter procedure resulted in a reduction of the mean aortic valve pressure gradient improved from 33 to 2 mmHg and a decrease in the shunt flow (Qp/Qs) from 1.9 to 1.2. The patient's heart failure improved, and he was discharged to home 7 days after the procedure. He remained well and had not been admitted to hospital since discharge.

Discussion: Trans-catheter aortic valve implantation using a valve skirt may be considered in a situation where a high-risk patient is inoperable and VSD closure devices are unavailable. To complete this procedure safely, meticulous pre-procedural evaluation and accurate positioning using trans-oesophageal echocardiogram are required.