Abstract
We report on a 69-year-old female patient with severe valvular aortic stenosis who was hospitalized for cardiac decompensation for aortic valve replacement. Preoperative imaging (X-Ray, cat-scan and CMR) revealed significant and extraordinary intramyocardial calcification pronounced globally in the left ventricle and around the mitral valve. Due to high operative/surgical risk we preferred to approach an aortic valve replacement by transfemoral transcatheter procedure (TAVI-TF). Within the context of an undeniably elevated risk for ventricular injuries and dissections in conventional operations, highly progressed myocardial calcifications should lead to consider and prefer the transfemoral transcatheter aortic valve replacement procedure. 
 Keywords: Aortic stenosis, intramyocardial calcification, transcatheter aortic valve replacement.
Highlights
Conventional aortic valve replacement (AVR) is the gold standard therapy to treat aortic stenosis, the most frequent cardiac valve disease [1, 2]
We report on a patient with severe aortic stenosis with diffuse myocardial calcification who was not suitable for conventional AVR but could be treated properly by TAVI-TF, forcing to consider TAVI in therapeutic decision making in cases with structural abnormalities and/or high operative risk
The aortic stenosis accompanied by moderate aortic regurgitation had been first diagnosed in this very decompensation with highly calcified tricuspid leaflets, an aortic annulus diameter of 18 mm, an aortic valve area of 0,7 cm2 and a peak (PPG) and mean pressure gradient (MPG) of 51 mmHg and 32 mmHg, respectively
Summary
Conventional aortic valve replacement (AVR) is the gold standard therapy to treat aortic stenosis, the most frequent cardiac valve disease [1, 2]. We report on a patient with severe aortic stenosis with diffuse myocardial calcification who was not suitable for conventional AVR but could be treated properly by TAVI-TF, forcing to consider TAVI in therapeutic decision making in cases with structural abnormalities and/or high operative risk. The patient showed a multiple valve disease with leading low-flow-low-gradient aortic stenosis with preserved ejection fraction, which may be caused by the concomitant mitral regurgitation, atrial fibrillation and paradox or restrictive ventricular filling because of the intramyocardial calcification. Due to these findings, the comorbidities, the significant intramyocardial calcification and fibrotic lesions we decided to treat the aortic stenosis with transfemoral transcatheter aortic valve implantation (TAVI-TF). Oral anticoagulation with phenprocoumon to maintain an INR between 2 and 3 was applied and recommended to avoid embolic events after valve implantation and with respect to the persistent atrial fibrillation
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