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We present a 43-year-old woman with a nonischemic cardiomyopathy implanted with a ventricular assist device (VAD) as bridge to transplant due to severe, “fixed” pulmonary hypertension (PH). Within three months of VAD implant, her “fixed” PH had resolved entirely. Nearly two years later, still supported with a VAD because of severe HLA allosensitization, she developed dyspnea and “moderate” aortic insufficiency (AI) by standard criteria. Invasive hemodynamics revealed recurrence of severe PH in the setting of elevated left-sided filling pressures. We concluded the AI was indeed severe and the cause of her symptoms and recurrent PH. Despite her minimally calcified aortic valve and small body habitus, after a thorough assessment, including meticulous annular measurements and appropriate valve sizing, she underwent a transcatheter aortic valve replacement (TAVR) with complete resolution of both her AI and recurrent, severe PH. This case highlights, in a single patient, reversal of “fixed” PH with adequate left ventricular unloading, that “moderate” AI by standard criteria is often “severe” and must be considered in a VAD patient with recurrent PH, and the need for meticulous pre-procedural planning for TAVR in patients with VADs, including accurate measurements of the aortic annulus to ensure adequate oversizing of the valve.



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