Annular Rupture Due to Calcified Nodule Located in Left Ventricular Outflow Tract (LVOT) During Transcatheter Aortic Valve Replacement (TAVR) Managed by Protamine Sulfate

Annular rupture is a rare yet fatal complication of transcatheter aortic valve replacement (TAVR). The likelihood of annular rupture is increased by the presence of extensive subannular calcification, excessive balloon dilatation for valve expansion or aggressive valve oversizing to prevent paravalvular leakage during TAVR. Although extensive annular or aortic root calcification increases the likelihood of annular rupture, rupture due to the presence of a calcified nodule in the left ventricular outflow tract (LVOT) is not commonly reported. We present the case of an 84-year-old man who developed an annular rupture during TAVR, likely due to the presence of a calcified nodule located in LVOT, which was noted on a pre-procedural computed tomography (CT) scan. The rupture was identified early and was successfully reversed with the administration of protamine sulfate during the procedure.