‘Touchdown’ technique during self-expandable transcatheter aortic valve replacement in patient with severe left ventricular outflow tract calcification: a case report

BACKGROUND: In transcatheter aortic valve replacement (TAVR), severe left ventricular outflow tract (LVOT) calcification is associated with a higher risk of aortic root rupture and paravalvular regurgitation (PVR), and is considered one of the challenging anatomies. We present a case of successful TAVR using a self-expandable valve without aortic root rupture or significant PVR by devising a deployment method and valve positioning. CASE SUMMARY: An 82-year-old woman was diagnosed with severe aortic stenosis. Computed tomography showed a suitable ilio-femoral artery for transfemoral TAVR, but indicated severe LVOT calcification protruding into the lumen. To avoid aortic root rupture, we planned TAVR using an Evolut-Pro+ self-expandable valve (EVP+). Furthermore, to control PVR, we implanted an EVP+ using a ‘touchdown’ technique: i) valve deployment was started above the aortic annulus, and the EVP+ stent tip landed on top of the LVOT calcification; and ii) EVP+ deployment was continued while confirming that the stent tip maintained contact with the top of the LVOT calcification without moving. Using this method, we successfully implanted an EVP+ at the intended position without significant PVR or valve embolization. DISCUSSION: In self-expandable valve implantation for patients with severe LVOT calcification, deployment should be carefully tailored to control PVR without valve embolization. A ‘touchdown’ technique can be a useful option for avoiding significant PVR in these cases.