Search Results (276)

Background/Objectives: Horizontal aorta, characterized by a high aortic angle, represents a challenging anatomical feature during transcatheter aortic valve replacement (TAVR), but its association with cerebral ischemic injury remains unclear. This study investigated the association between horizontal aorta and diffusion-weighted magnetic resonance imaging (DW-MRI)-detected cerebral infarctions after TAVR. Methods: We retrospectively enrolled 411 consecutive patients with severe aortic stenosis undergoing transfemoral self-expanding TAVR between March 2017 and May 2022. Aortic angle was defined as the angle between the aortic annular plane and the horizontal plane on preprocedural computed tomography, and horizontal aorta was defined as an aortic angle > 60°. Patients were categorized into horizontal aorta and non-horizontal aorta groups. The incidence, number, and volume of new DW-MRI lesions were compared between groups. Results: The median age was 74.0 years (interquartile range [IQR]: 69.0 to 79.0); 54.5% were male, and the median Society of Thoracic Surgeons score was 3.83% (IQR: 2.29 to 6.39). Horizontal aorta was present in 69 patients (16.8%). Procedural complications were infrequent and comparable between groups. Although the incidence of new cerebral infarctions was similar between groups (89.9% vs. 83.0%; p = 0.157), patients with horizontal aorta had more cerebral infarction lesions (median, 4.0 vs. 3.0; p = 0.031), larger total lesion volume (320.0 vs. 180.0 mm³; p = 0.017), and larger lesion volume per infarction (70.0 vs. 51.7 mm³; p = 0.036). Multivariable analysis identified horizontal aorta as an independent predictor of the number of post-TAVR cerebral infarctions. Conclusions: Horizontal aorta is relatively common among patients undergoing TAVR and is independently associated with a greater burden of DW-MRI-detected subclinical cerebral ischemic injury. Full article

Background: The incidence and predictors of major adverse cardiovascular and cerebrovascular events (MACCE) in patients undergoing percutaneous coronary intervention (PCI) and transcatheter aortic valve replacement (TAVR) during the same hospitalization remain poorly characterized, particularly in Asian populations. Methods: This single-center retrospective study included 164 consecutive patients who underwent PCI and transfemoral TAVR during the same hospitalization at Beijing Anzhen Hospital between June 2018 and October 2023. The primary objective was to evaluate the incidence of MACCE, and logistic regression analyses were used to identify its predictors. Results: Among 164 patients, the mean age was 73.9 ± 7.2 years, and 57.9% were male. Device success was 97.6% and procedural success was 89.6%. MACCE occurred in 28 patients (17.1%) within the index hospitalization or 30 days after discharge. Independent predictors of MACCE were lower baseline left ventricular ejection fraction (LVEF; OR = 0.955, 95% CI 0.920–0.992; p = 0.017) and mixed aortic stenosis and regurgitation (AS + AR; OR = 6.360, 95% CI 1.035–38.993; p = 0.038). Conclusions: A single-hospitalization PCI and TAVR strategy appeared feasible and was associated with acceptable short-term clinical outcomes in carefully selected Chinese candidates, with lower baseline LVEF and mixed AS and AR as independent predictors of MACCE. The observed clinical outcomes should be interpreted descriptively because of the lack of a contemporaneous comparator group; large-scale prospective studies are needed to further evaluate the safety and clinical benefit of this “one-stop” paradigm. Full article

Background/Objectives: Infective endocarditis (IE) is a life-threatening cardiovascular infection with in-hospital mortality of 15–30% despite modern therapy. Contemporary IE demonstrates non-random valve involvement: aortic and mitral 35–45%, tricuspid 5–10% (30–50% in intravenous drug users [IVDU]), and pulmonary < 1%. These patterns implicate valve-specific anatomy and hemodynamics as central determinants of susceptibility. This narrative review examines the reported distribution of IE across the aortic, mitral, tricuspid and pulmonary valves and summarises the anatomical, haemodynamic, structural, microbial and patient-related factors associated with valve-specific susceptibility. Methods: A structured narrative review of English-language literature was conducted using PubMed/MEDLINE, Embase, Scopus, and Google Scholar (January 1990–March 2026). Search terms included “infective endocarditis,” “valve anatomy,” “hemodynamics,” “bicuspid aortic valve,” “prosthetic valve endocarditis,” and “transcatheter aortic valve replacement (TAVR) endocarditis.” We included anatomical studies, clinical cohorts, surgical series, imaging research, and international guidelines. Evidence was synthesized narratively using Oxford Centre for Evidence-Based Medicine (CEBM) levels. Results: IE susceptibility follows a biologically coherent gradient determined by the interaction between valve anatomy, hemodynamic stress, endothelial injury, and structural substrate. The aortic valve is most vulnerable because of high shear stress, congenital abnormalities such as bicuspid aortic valve, and direct continuity with the cardiac fibrous skeleton, predisposing to peri-annular extension. Mitral valve IE is largely conditional upon pre-existing structural disease, particularly mitral valve prolapse, rheumatic heart disease, and mitral annular calcification, and is characterized by a high risk of systemic embolization. Tricuspid valve IE reflects the interaction between low-pressure hemodynamics and acquired patient-specific modifiers, including intravenous drug use, cardiovascular implantable electronic devices, and congenital heart disease. Pulmonary valve IE remains uncommon because of favorable native hemodynamics but occurs predominantly in repaired congenital heart disease, right ventricular outflow tract reconstruction, and prosthetic pulmonary valves. Across all valve types, multimodality imaging and anatomical assessment consistently influence complication detection, surgical planning, and long-term surveillance. Conclusions: IE involvement is unevenly distributed among the cardiac valves. Aortic and mitral involvement predominate, tricuspid involvement is strongly influenced by injection drug use and intracardiac devices, and pulmonary-valve IE remains rare and is principally associated with congenital abnormalities or prosthetic material. These patterns highlight the possible contributions of haemodynamic stress, pre-existing structural abnormalities, and age-related valvular changes to the greater susceptibility of left-sided valves. Full article

Background/Objectives: Leaflet thrombosis after transcatheter aortic valve replacement (TAVR), typically identified as hypoattenuated leaflet thickening (HALT) on multidetector computed tomography (MDCT), is increasingly recognized as an early manifestation of bioprosthetic valve dysfunction. However, factors associated with early HALT in Southeast Asian populations remain poorly characterized. The objective of this study was to characterize MDCT features of leaflet thrombosis and identify factors independently associated with early HALT after TAVR. Methods: In this two-center observational study, patients undergoing MDCT 1–3 months after TAVR were evaluated. Leaflet thrombosis was defined as HALT. Leaflet involvement, thrombus severity, anatomical distribution, and post-implantation geometric parameters were analyzed. Multivariable logistic regression identified factors associated with early HALT. Results: Among 65 patients, HALT was detected in 30.8%, predominantly as subclinical leaflet thrombosis (29.2%), whereas clinical valve thrombosis was rare (1.5%). Most cases involved one or two leaflets, with preferential involvement of the non-coronary cusp. Patients with HALT showed greater increases in transvalvular peak gradients, and a peak gradient increase ≥10 mmHg was more frequent than in patients without HALT (30.0% vs. 4.4%; p = 0.008). Severe RCA ostial eccentricity (grade 3–4) combined with a neo-sinus–RCA distance > 13 mm was independently associated with HALT (adjusted OR 5.52; p = 0.006). Lack of left ventricular ejection fraction improvement after TAVR was also independently associated with HALT (adjusted OR 4.44; p = 0.018), though given the limited number of HALT events (n = 20), these multivariable associations should be regarded as exploratory and hypothesis-generating. Conclusions: Early post-TAVR leaflet thrombosis is common and predominantly subclinical. CT-derived neo-sinus geometry and impaired ventricular recovery were independently associated with HALT, supporting the hypothesis that altered neo-sinus washout contributes to thrombus formation. Full article

Background: Invasive coronary angiography has historically been the reference standard for coronary, valvular, and structural heart disease. Over the past decade, coronary computed tomography angiography (CCTA), CT-derived fractional flow reserve (CT-FFR), photon-counting detector computed tomography (PCCT), and cardiac magnetic resonance (CMR) have expanded the range of clinical questions answerable without an intra-arterial catheter, but this shift has been uneven across clinical domains. Methods: We performed a narrative review and synthesis of randomized trials, registries, society guidelines, and consensus documents (2009–2026) identified through PubMed and major cardiovascular guideline databases, written from a joint cardiology and cardiac-surgical standpoint. Results: The boundary has shifted asymmetrically, by which we mean a domain-dependent rather than uniform displacement of invasive angiography. Non-invasive imaging is now established as the first-line approach for stable chest pain at low-to-moderate pretest probability, for pre-transcatheter aortic valve replacement (TAVR) and structural procedural planning, and for aortic disease. It remains contested for stable multivessel disease and pre-coronary artery bypass grafting (CABG) planning, where CCTA- or CT-FFR-only planning is still investigational. Invasive angiography stays first-line for ST-elevation myocardial infarction (STEMI), cardiogenic shock, and complex percutaneous coronary intervention (PCI), where diagnosis and therapy are inseparable. Conclusions: Invasive and non-invasive modalities are complementary rather than competing. The appropriate first-line investigation depends on the disease domain, pretest probability, anatomical complexity, imaging quality, and whether diagnosis and treatment can be separated. We propose a complexity-stratified, heart-team framework and identify the surgical research gaps that remain. Full article

Background: Comparisons between transcatheter and surgical aortic valve replacement (TAVR or SAVR) in younger aortic stenosis (AS) patients are scarce. The aim of the study was to evaluate the 5-year outcomes of AS patients <75 years undergoing TAVR or SAVR. Methods: This was a single-center study that retrospectively included AS patients <75 years who underwent transfemoral TAVR or SAVR from a Chinese real-world database (2014–2023). The primary outcome was defined as the composite of all-cause death, stroke, and cardiovascular rehospitalization at 5 years post-procedure. Robust risk adjustment was performed using inverse probability weighting (IPTW), multilevel regression models, and competing-risk analysis. Sensitivity analyses included comparison between TAVR and mechanical or bioprosthetic SAVR separately in the overall cohort and patients with bicuspid aortic valve (BAV). Results: A total of 1646 patients undergoing TAVR (n = 808) or SAVR (n = 838) were finally included. At baseline, TAVR patients had an older age [(67.9 ± 5.2) vs. (56.5 ± 9.6) years, p < 0.001] and a higher surgical risk score [(3.1 ± 1.5) vs. (2.1 ± 1.0) %, p < 0.001] than SAVR patients, which was well balanced after IPTW. The 5-year adjusted risk of the primary outcome was similar (TAVR 45.9% vs. SAVR 43.4%, weighted hazard ratio, 1.00, 95% confidence interval, 0.64–1.54, p = 0.986), which stayed comparable between TAVR and mechanical or bioprosthetic SAVR separately. In BAV patients (n = 516), the risk of death was 8.3% in the TAVR group and 3.4% in the SAVR group (p = 0.349). The risk of bioprosthetic structural valve deterioration at 5 years was comparable between groups in the overall cohort (5.7% vs. 8.4%, p = 0.478) and BAV patients (7.8% vs. 13.2%, p = 0.345). Conclusions: In this retrospective study of patients aged <75 years, the risk-adjusted 5-year major clinical outcomes were statistically similar between TAVR and SAVR. However, given the inherent historical imbalances, these exploratory findings should be interpreted with caution, and dedicated prospective studies are still needed in younger and BAV populations. Full article

Background and Objectives: Transcatheter aortic valve replacement (TAVR) has become an established treatment for severe symptomatic aortic stenosis, and continuous technological advances have led to the development of different transcatheter heart valve (THV) systems. This study aimed to compare the short- and mid-term clinical outcomes of the balloon-expandable Myval (Meril Life Sciences, India) and the self-expanding Acurate Neo (Boston Scientific, MA, USA) transcatheter heart valves during a mean follow-up of 18 months. Materials and Methods: This retrospective single-center study included consecutive patients who underwent transfemoral TAVR with either the Myval or Acurate Neo valve between January 2020 and September 2022. Demographic, clinical, laboratory, electrocardiographic, echocardiographic, procedural, and follow-up data were collected and compared. Clinical outcomes were evaluated according to the Valve Academic Research Consortium-3 (VARC-3) criteria. Results: A total of 147 patients were included (Myval, n = 116; Acurate Neo, n = 31). Predilatation was performed in all patients in the Acurate Neo group but in only 22 (18.9%) patients in the Myval group (p < 0.001). In-hospital mild paravalvular leak (PVL) was more frequent in the Acurate Neo group (38.7% vs. 20.6%; p = 0.038), whereas moderate or greater PVL did not differ between the groups. During a mean follow-up of 18 months (range, 10–32 months), mild PVL remained significantly more frequent in the Acurate Neo group (p = 0.028). No significant differences were observed between the two valve systems regarding mortality, permanent pacemaker implantation, or other major VARC-3 clinical outcomes. Conclusions: The Myval and Acurate Neo transcatheter heart valves demonstrated comparable short- and mid-term clinical outcomes in patients undergoing TAVR. Although mild PVL was more frequent with the Acurate Neo valve, mortality, permanent pacemaker implantation, and moderate or greater PVL were similar between the two valve systems, supporting the safety and effectiveness of both prostheses in the treatment of severe symptomatic aortic stenosis. Full article

Background/Objectives: Post-procedural permanent pacemaker implantation (PPMI) and cardiac damage are individually associated with adverse outcomes following transcatheter aortic valve replacement (TAVR). However, their joint impact has not been systematically evaluated. Methods: Individuals who underwent TAVR procedures between 2013 and 2024 were retrospectively enrolled and classified into four groups based on their PPMI and cardiac damage status. Univariate and multivariable Cox regression were used to analyze the association of these factors with long-term outcomes, while receiver operating characteristic (ROC) curves, decision curve analysis (DCA), net reclassification improvement (NRI), and integrated discrimination improvement (IDI) were used to further assess their predictive performance. Results: A total of 1274 patients met the inclusion criteria. Compared to non-PPMI patients with early cardiac damage stage, those with PPMI and advanced stage had higher all-cause mortality (HR: 2.98; 95% CI: 1.60–5.56; p value < 0.001) and more cardiac deaths (HR: 3.85; 95% CI: 1.36–11.10; p = 0.012). Multivariable analysis confirmed PPMI and cardiac damage stage as independent prognostic factors. Notably, the predictive model incorporating both variables achieved the best performance (AUC = 0.703) with significant NRI and favorable DCA results, suggesting incremental value for identifying high-risk patients and acceptable clinical utility. Conclusions: The current study is among the first to explore whether post-procedural cardiac damage may identify a subgroup in whom PPMI carries a particularly adverse long-term prognosis, highlighting the need for integrated risk assessment for post-TAVR lifelong management. Full article

The coexistence of severe aortic stenosis (AS) and coronary artery disease (CAD) is common and presents important diagnostic and therapeutic challenges, particularly in patients being considered for transcatheter aortic valve replacement. Accurate assessment of coronary lesion significance in this setting is difficult because severe AS alters coronary haemodynamics, myocardial oxygen demand, microvascular function, and the balance between resting and hyperaemic flow. These changes may influence the interpretation of conventional physiological indices and complicate decisions regarding revascularisation. This narrative review summarises the pathophysiological interaction between severe AS and CAD and examines the contemporary evidence supporting invasive and non-invasive approaches to coronary assessment. We review the limitations and potential utility of fractional flow reserve, and non-hyperaemic pressure ratios, highlighting the frequent discordance observed between indices and the uncertainty regarding optimal thresholds in severe AS. Importantly, identification of physiologically significant lesions should be distinguished from evidence that revascularisation of these lesions improves clinical outcomes, as prospective outcome data remain limited. While recent trials support physiology-guided revascularisation in patients undergoing TAVR, outcome data remain linked primarily to conventional FFR thresholds rather than proposed AS-specific cutoffs. We also discuss emerging non-wire-based approaches, including quantitative flow ratio and computed tomography-derived fractional flow reserve, which may offer complementary value in selected patients. In addition, we examine the practical implications of coronary physiology for clinical decision-making before and after valve intervention, including the timing of percutaneous coronary intervention and the need to distinguish lesion-level diagnostic performance from evidence of clinical benefit. Current data suggest that no single modality is universally applicable and that assessment should be individualised according to lesion characteristics, clinical context, and procedural strategy. Proposed severe AS-specific thresholds for FFR and NHPR are derived from small predominantly observational studies, have not been prospectively validated against clinical outcomes and should be hypothesis-generating. A hybrid approach integrating angiographic, physiological, and computed tomography-based information may be most useful. Further prospective studies are needed to define optimal thresholds, validate management algorithms, and clarify whether physiology-guided strategies improve outcomes in severe AS. Full article

Transcatheter Aortic Valve Implantation/Replacement (TAVI/TAVR) has come a long way since the first-in-human implant by Prof Cribier & colleagues in 2002. Initially a consideration for inoperable/high-surgical-risk patients, TAVI is now indicated in patients with severe tricuspid aortic stenosis and suitable anatomy aged 70 or higher. This has been made possible due to improvements in preprocedural planning, performance upgrades to and evolution of transcatheter heart valve (THV) systems and increasing operator experience. Younger age at index implantation, complexities of redo TAVI planning and methods to improve THV durability are the next frontiers. This review summarizes these advancements while emphasizing preprocedural planning, current guidelines, and individualized device selection, with a brief note on polymeric heart valves—developed to overcome the disadvantageous bioprosthetic dysfunction seen with current THVs. Full article

Introduction: Transcatheter aortic valve replacement (TAVR) has become the predominant treatment for severe aortic stenosis across all surgical risk categories. However, its role in patients aged 65 years and younger remains uncertain, and current guideline recommendations continue to favor surgical aortic valve replacement (SAVR) in this population. Despite this, contemporary real-world data demonstrate a marked increase in TAVR utilization among younger patients, creating an important gap between guidelines and clinical practice. Methods: This review synthesizes contemporary observational evidence evaluating TAVR in patients ≤65 years, with a focus on patient selection, clinical outcomes, and lifetime management considerations. Results: Available studies demonstrate that younger patients undergoing TAVR often represent a highly selected and clinically complex population with greater comorbidity burden, higher surgical risk, and shorter life expectancy than age-matched SAVR recipients, yet substantial hospital-level variation in TAVR utilization exists even after risk adjustment. Mid-term observational data suggest higher mortality and heart failure readmission rates following TAVR compared with SAVR, although these findings are likely influenced by substantial baseline differences between treatment groups. No randomized controlled trial has specifically compared TAVR and SAVR in patients ≤65 years. Furthermore, long-term issues including valve durability, coronary access, redo-TAVR feasibility, and THV optimization remain incompletely understood. Conclusions: TAVR recipients ≤65 are often a clinically distinct group characterized by significantly heavier comorbidity burdens than SAVR recipients of the same age with standard surgical risk models possibly underestimating the true clinical risk. Despite this, significant hospital-level variation in TAVR utilization persists even after risk adjustment, suggesting that institutional practice patterns and other non-clinical factors continue to influence treatment selection. Full article

Objectives: Severe aortic stenosis (AS) with cardiogenic shock (CS) presents a complex clinical challenge. For these patients, the optimal management strategy—either direct transcatheter aortic valve replacement (TAVR) or a staged approach with balloon aortic valvuloplasty (BAV) as a bridge to TAVR (BAV-TAVR)—is uncertain. We aimed to compare the outcomes of these two strategies. Methods: We conducted a retrospective cohort study using the TriNetX database. In this study, we identified patients with CS who underwent direct TAVR or who survived to and underwent TAVR within 30 days of balloon aortic valvuloplasty (BAV-TAVR). After matching propensity scores, 198 patients were analyzed in each group (total of 396). The primary outcome was major adverse cardiovascular events (MACE) at 30 days, 1 year, and 3 years. Results: The analysis included 396 matched patients (198 in each cohort). There was no significant difference in the primary endpoint of MACE at 30 days between the staged BAV and direct TAVR groups HR 1.14 (95% CI 0.79–1.64; p = 0.48), and this finding was consistent at 1 and 3 years with HR 1.20 (95% CI 0.89–1.61; p = 0.23) and HR 1.17 (95% CI 0.89–1.53; p = 0.25) respectively. Similarly, no differences were observed in secondary outcomes including all-cause mortality, stroke, and new permanent pacemaker implantation, at 30 days, 1, and 3 years. Conclusions: Among patients with severe AS and cardiogenic shock who survived definitive therapy, staged BAV-TAVR showed no detectable difference in short- or long-term outcomes versus direct TAVR. Given the limited sample size and the exclusion of patients who did not survive to TAVR, these results are hypothesis-generating and should not be read as evidence of equivalence or of bridging safety; prospective study is warranted. Full article

Background/Objectives: Hypoattenuated leaflet thrombosis (HALT) is a frequent finding after transcatheter aortic valve replacement (TAVR). Although high residual platelet reactivity (HPR) increases thrombotic risk after coronary stent implantation, its role in HALT remains unclear. This study aimed to determine the incidence and predictors of HALT in TAVR patients treated with dual antiplatelet therapy, focusing on the impact of HPR. Methods: This was a prospective, multicenter observational study. Between June 2018 and February 2022 patients with symptomatic severe aortic stenosis undergoing successful TAVR and treated with dual antiplatelet therapy for 3 months were included. Platelet reactivity was assessed 1–3 months post-TAVR using either VerifyNow (72%) or the Multiplate Analyzer (28%). HALT was evaluated using contrast-enhanced multidetector computed tomography. Results: A total of 169 patients were included (mean age 81.5 ± 5 years; 51% female). The incidence of HALT was 22%. Independent predictors of HALT were self-expanding valve (OR 3.05; 95% CI, 1.30–7.14; p = 0.010). Protective factors included larger prosthesis size (OR 0.78; 95% CI, 0.65–0.93; p = 0.007), statin-treated dyslipidemia (OR 0.37; 95% CI, 0.16–0.88; p = 0.024), and higher creatinine clearance (OR 0.98; 95% CI, 0.96–1.00; p = 0.035). HALT incidence was similar in patients with and without HPR (23.7% vs. 33.6%; p = 0.29). No differences in clinical outcomes were observed at 1 year. Conclusions: HALT occurred in nearly one-quarter of TAVR patients treated with dual antiplatelet therapy and was unrelated to platelet reactivity. Valve characteristics, renal function, and statin-treated dyslipidemia were associated with HALT, highlighting the multifactorial nature of its development. Full article

Background/Objectives: Permanent pacemaker implantation (PPI) remains one of the most common complications following transcatheter aortic valve replacement (TAVR). Identifying patients at increased risk for post-procedural conduction disturbances is clinically important for procedural planning and patient management. The aim of this study was to develop and evaluate a machine learning-based model for predicting the risk of PPI after TAVR. Methods: This prospective study was conducted between 2019 and 2025, and included 179 patients with severe aortic stenosis who underwent TAVR. Patient eligibility was determined by a multidisciplinary Heart Team based on clinical, echocardiographic, and imaging criteria. The primary endpoint was PPI occurring during hospitalization or within 30 days after the procedure. Statistical analyses were performed using RStudio (v. 2024.09.1+394)and Python (v.3.12.3), including comparative tests for continuous and categorical variables, receiver operating characteristic analysis to assess model performance, and SHapley Additive exPlanations (SHAP) to evaluate feature importance and model interpretability. Results: A total of 179 patients undergoing TAVR were included in the analysis. PPI occurred in 17 patients (9.5%) within 30 days after the procedure. A machine learning model was developed to predict post-TAVR PPI. The model demonstrated good predictive performance, with an overall accuracy of 0.944 and a weighted F1-score of 0.947. The confusion matrix showed that the model correctly classified 155 patients without PPI and 14 patients with PPI, with only a small number of false predictions. Explainability analyses using SHAP and permutation feature importance revealed that anatomical and procedural variables had the greatest impact on model predictions. The most influential predictors included valve size, right coronary sinus diameter, prosthetic valve diameter, and mean aortic annulus diameter. In contrast, baseline clinical variables such as left ventricular ejection fraction, previous myocardial infarction, and mean transaortic gradient showed a comparatively lower contribution to the prediction of PPI after TAVR. Conclusions: This study demonstrates that machine learning models can effectively predict the risk of PPI after TAVR. Anatomical characteristics of the aortic root and prosthesis-related parameters were the main determinants of PPI, whereas baseline clinical variables had a lower impact. The use of explainable artificial intelligence methods, such as SHAP analysis, may improve risk stratification and support procedural planning in patients undergoing TAVR. Full article

Background: An aorto-right ventricular fistula (ARVF) secondary to membranous septum rupture is an exceptionally rare complication after surgical aortic valve replacement (SAVR). While sutureless prostheses such as the Perceval valve have gained wide acceptance due to reduced cross-clamp times and procedural simplification, the reported adverse events predominantly include conduction disturbances and paravalvular leaks. Structural septal disruption remains sparsely described. We report a case of an early ARVF after Perceval implantation and review the pathophysiological and procedural mechanisms implicated in septal injury following sutureless and transcatheter aortic valve interventions. Case Description: A 66-year-old woman with severe bicuspid aortic valve stenosis underwent SAVR via a median sternotomy using a Perceval XL prosthesis after meticulous annular decalcification and sizing. Immediate intraoperative transesophageal echocardiography (TEE) confirmed optimal seating without any paravalvular regurgitation. Within 24 h, the patient developed a complete atrioventricular block followed by cardiogenic shock. A repeat TEE revealed a large ARVF with significant left-to-right shunt. Emergent re-exploration identified a membranous septum tear. The Perceval prosthesis was explanted, the defect was closed with a reinforced patch repair, and a 27 mm Inspiris Resilia bioprosthesis was implanted. Peripheral veno-arterial ECMO support was required temporarily. The patient recovered and remained free of prosthetic dysfunction at the two-year follow-up. Discussion: Membranous septum rupture after AVR has an estimated incidence of 0.4–1.5% in TAVR cohorts but is virtually unreported with Perceval valves. The mechanisms are thought to be chronic radial stress from oversized or malpositioned prostheses. Case reports with TAVR devices emphasize oversizing as a risk factor. Predictive factors for septal injury in sutureless AVR mirror those for conduction disturbances: valve oversizing, shallow infra-annular septal length, heavy calcification, and prior valve surgery. Preventive measures, such as strict sizing protocols, the avoidance of balloon dilation, and optimized implantation depth, have reduced conduction complications and may mitigate septal trauma. The treatment choice, whether percutaneous or surgical closure, depends on hemodynamic stability, defect size and anatomy, and operative risk. Conclusions: Early ARVF after Perceval implantation is exceedingly rare but potentially catastrophic. Strict adherence to sizing principles, awareness of septal anatomy, and prompt management, percutaneous in selected stable cases or surgical in acute large defects, are essential to optimize outcomes in sutureless AVR. Full article