High calcium, high stakes: managing severe AS with complex multivessel disease
A 69-year-old woman with severe symptomatic aortic stenosis (NYHA III) and complex comorbidities, including three-vessel coronary artery disease, advanced COPD, and peripheral artery disease, presents with progressive dyspnoea despite recent PCI. How would you treat this patient?
Authors
Patient
- Female
- Age: 69 years
- Height: 180 cm
- Weight: 61 kg
- BSA: 1.83 m²
- BMI: 18.8
- Retired
- Active at home
- Exertional dyspnea, NYHA class III
Medical history
Cardiovascular risk factors (CVRF):
- Arterial hypertension
- Nicotine abuse (currently ~7 cigarettes/day, previously cumulative ~50 pack-years)
- Hypercholesterolemia
Coronary artery disease (three-vessel disease)
- Coronary angiography 12/2025 external
- Left main (LM): No stenosis, minor wall irregularities, LAD: severe stenosis of distal diagonal branch, LCx: heavily calcified proximal and mid segments with severe stenosis; RCA: High-grade ostial stenosis, subtotal proximal stenosis
Interventions:
- PCI proximal and mid LCx: IVUS-guided PTCA, rotational atherectomy, and implantation of 2 DES with excellent result (12/2025), failed wiring attempt of heavily calcified RCA lesion (balloon uncrossable)
Pulmonary disease
- Clinical limitation due to advanced obstructive lung disease
- Significant pulmonary emphysema
Gastroenterological history
- Status post cholecystectomy
- History of gallbladder adenoma
- Type C gastritis
Vascular disease
- PAD Stage II according to Rutherford bilateral
- Atherosclerosis with macroangiopathy of the carotid arteries
- History of right tumor nephrectomy
Oncological history
- Status post right-sided tumour nephrectomy for ureteral carcinoma (05/2023)
Diagnostics
TTE (pre):
- Pmax/mean: 65/42 mmHg
- Vmax: 4.0 m/s
- Aortic valve area (AVA): 0.8 cm²
CT:
- Agatston score: 1797.61
VALVE pictures
ACCESS pictures
Left
Right
Stretched Vessel - Right Subclavian Artery
TAX:
Stretched Vessel - Left Subclavian Artery
Learning objectives
- Learn how to anticipate the anatomical challenges that may arise during TAVI for tricuspid aortic stenosis
- Understand how to plan for TAVI in patients with a large aortic annulus
- Learn effective strategies for planning and performing TAVI in tricuspid aortic stenosis cases involving a horizontal aorta
Dr. Adam reports the following disclosures:
- Honoraria from Abbott, Edwards Lifesciences, Jenavalve, Medtronic and Meril
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