Emergency transcatheter aortic valve replacement in a 35-year-old patient with unicuspid aortic valve disease and cardiogenic shock

A 35-year-old man was transferred from an external hospital with acute decompensated heart failure due to unicuspid aortic valve disease with severe aortic stenosis (mean gradient 48 mmHg, aortic valve area 0.5 cm², Panel A) and severe aortic regurgitation (pressure half-time 185 ms, Panel B). Left ventricular ejection fraction (LVEF: 39%) was reduced, the right ventricle was dilated and impaired, and tricuspid regurgitation was severe (Panel C). The patient’s condition rapidly deteriorated, leading to multiorgan failure with cardiogenic shock, hypotension, lactate of 8 mmol/L, and acute renal and liver failure. Due to a significantly elevated risk (EuroSCORE II: 31.79), emergent surgical aortic valve replacement was declined, and the local heart team recommended immediate rescue transcatheter aortic valve replacement (TAVR).

Transcatheter aortic valve replacement was performed uneventfully under conscious sedation by the implantation of a 26 mm Edwards SAPIEN 3 Ultra prosthesis. The final angiogram revealed mild residual aortic regurgitation attributed to pronounced focal calcification and an asymmetric final valve position (Panel D). Post-dilation was omitted due to the high risk of aortic root rupture.

A post-interventional transthoracic echocardiogram demonstrated regular aortic valve opening with moderate paravalvular leakage (Panel E), an improved LVEF (49%), and a reduction to mild tricuspid regurgitation (Panel F). The patient was weaned of vasopressors the same day, continuous dialysis was successfully terminated the day after, and renal and liver function normalized (Panel G). Three days after TAVR, he was transferred to a normal ward. This case illustrates that TAVR can be a feasible rescue option for deteriorating patients with cardiogenic shock, even in special populations and challenging anatomy