Transcatheter aortic valve implantation (TAVI) in bicuspid aortic valve (BAV) poses unique challenges. We report a case in which an apparently benign anatomy resulted in failure of conventional delivery strategies and required a novel balloon-assisted bailout technique.

Coronary artery anomalies are rare but clinically significant malformations, particularly when involving an interarterial course, which predisposes to ischemia and sudden cardiac death. We report the case of a previously healthy 22-year-old man who suffered out-of-hospital cardiac arrest associated with recreational inhalant use. Imaging revealed an anomalous right coronary artery originating from the left sinus of Valsalva with interarterial trajectory. Surgical reimplantation was performed under tailored anesthetic management emphasizing hemodynamic stability. The patient recovered uneventfully. This case discusses and highlights anesthetic priorities and the potential role of external triggers in vulnerable coronary anatomy.

BackgroundBioprosthetic aortic valve replacement, specifically surgical (SAVR) and transcatheter (TAVR), is among the most frequently performed cardiac interventions globally, yet anticoagulation strategies after implantation remain incompletely defined. Atrial fibrillation, notably prevalent pre- and post-operatively in these patients, substantially amplifies thromboembolic risk and complicates decision-making in an already elderly, frail, and comorbid population.ObjectivesTo critically evaluate current anticoagulation strategies after bioprosthetic aortic valve replacement across sinus rhythm and atrial fibrillation in both SAVR and TAVR, and to identify evidence gaps and guideline inconsistencies.MethodsWe conducted a narrative review of major international guidelines (ESC/EACTS 2025, ACC/AHA 2020, and NICE 2021) and key clinical trials on antithrombotic therapy in valve replacement populations. Focus was placed on bioprosthetic aortic valve replacement, with mechanical and non-aortic valves excluded.ResultsAspirin monotherapy is the most consistently supported strategy after bioprosthetic TAVR in sinus rhythm, though guidelines diverge on duration and recommendation strength. In atrial fibrillation, all three guidelines apply uniform CHA2DS2-VASc-based frameworks irrespective of AF phenotype, procedural context, or detection modality, reflecting lacking evidence rather than deliberate clinical judgement. No trial has enrolled patients specifically with new-onset post-procedural AF or stratified by AF subtype, and subclinical AF after bioprosthetic AVR remains entirely uncharacterised.ConclusionsGuideline divergence reflects a structurally inadequate evidence base rather than genuine clinical equipoise. Individualised decisions informed by procedure type, AF phenotype, frailty, and bleeding risk are required to guide clinical practice, alongside an adequately powered stratified randomised trial incorporating mandatory continuous rhythm monitoring.

Antegrade cardioplegia delivery during cardiopulmonary bypass (CPB) is standard practice in cardiac surgery, but it carries a risk of perfusion failure and acute myocardial distension in the presence of aortic regurgitation (AR). In patients with a bicuspid aortic valve (BAV), acute exacerbation of AR can occur immediately after initiating CPB. An 80-year-old man with a bicuspid aortic valve (Sievers classification type 1: L/R fusion), severe aortic stenosis, mild AR, and an ascending aortic aneurysm underwent elective aortic valve replacement and ascending aortic replacement. Immediately after starting CPB and entering ventricular fibrillation (VF), the patient developed sudden, severe AR (vena contracta: 10 mm). This caused rapid left ventricular (LV) dilation and subsequent dislodgement of the LV vent cannula into the left atrium. Real-time transesophageal echocardiography (TEE) promptly identified both the severe AR and the cannula displacement. Following aortic cross-clamping, antegrade cardioplegia failed due to massive regurgitant volume overload into the LV. Prophylactically placed retrograde cardioplegia via the coronary sinus was immediately initiated, successfully achieving rapid cardiac arrest. The planned surgical procedures were completed successfully without further complications, and the patient was discharged in good condition on postoperative day 11. In this patient, the acute exacerbation of AR was likely driven by two key factors: first, a rapid elevation in the transvalvular pressure gradient following CPB onset and VF; and second, the unmasking of latent coaptation failure, stemming from BAV asymmetry and calcification, due to the loss of myocardial tone during VF. Real-time TEE monitoring and prophylactic placement of a retrograde cardioplegia cannula are critical for rapid diagnosis, troubleshooting, and ensuring effective myocardial protection.

Transcatheter aortic valve implantation (TAVI) for structural valve deterioration (SVD) following surgical aortic valve replacement (SAVR) is an established alternative to redo surgery (transcatheter aortic valve-in-surgical aortic valve, or TAV-in-SAV). However, in patients with a small aortic annulus or small sinus of Valsalva (SOV), the risk of coronary artery obstruction or severe prosthesis-patient mismatch (PPM) remains a major constraint. To address this, we previously introduced the "3D-Nicks" procedure, using a preoperatively prepared three-dimensional ellipsoidal patch to achieve circumferential aortic root enlargement. We report a 14-year successful clinical course of TAV-in-SAV following SAVR with the 3D-Nicks procedure. A 61-year-old woman with severe aortic valve stenosis (AS) and a narrow aortic root (annulus 19 mm, STJ 20 mm) underwent SAVR (CEP19[®︎] mm, Edwards Lifesciences, Irvine, CA) combined with the 3D-Nicks technique. Around 14 years postoperatively, she developed severe SVD. Contrast CT demonstrated that 3D-Nicks had maintained ample root geometry (SOV 30.2-36.8 mm, STJ 31.8 mm, VTC > 5.0 mm, VTSTJ > 6.0 mm). TAV-in-SAV was successfully performed using a 23 mm Evolut FX[®︎] valve (Medtronic, Minneapolis, MN) via transfemoral access without coronary protection. Postoperative echocardiography showed excellent hemodynamics (mean PG 6 mmHg, EOAi 1.29 cm[2]/m[2]), which remained stable at the three-year follow-up (EOAi 1.16 cm[2]/m[2]). This case highlights that the 3D-Nicks procedure may provide favorable three-dimensional aortic root dimensions that facilitate safe long-term TAV-in-SAV.

Persistent left superior vena cava (PLSVC) with absent right superior vena cava (RSVC) is a rare congenital venous anomaly resulting from the failure of the left anterior cardinal vein to regress. Although often asymptomatic in isolated cases, prenatal diagnosis has clinical benefits, including the exclusion of coexisting congenital heart disease (CHD) and awareness of possible complications during central venous access or pacemaker implantation. We report the case of a 34-year-old G2P1 woman who underwent a fetal echocardiography at 34 weeks of gestation. Examination of the four-chamber view (4CV) revealed an enlarged coronary sinus adjacent to the left atrium, suggesting a PLSVC. Subsequent assessment of the right ventricular outflow tract (RVOT) and three-vessel view (3VV) confirmed the absence of the RSVC and presence of a persistent left superior vena cava (LSVC). Color and spectral Doppler imaging of the aortic arch and isthmus showed no narrowing, ruling out coarctation of the aorta. The pregnancy progressed uneventfully, and the patient had a spontaneous vaginal delivery at 38 weeks, resulting in a healthy newborn. Postnatal evaluations, including echocardiography, confirmed PLSVC draining into a dilated coronary sinus, with no additional cardiac anomalies identified. Although truly isolated, PLSVC typically does not require special delivery planning or postnatal intervention; prenatal recognition allows clinicians to ensure thorough fetal cardiac evaluation, offer appropriate counseling, and plan for potential challenges with right-sided central venous access in the future.