Two-Staged Transcatheter Aortic Valve Replacement in Severely Calcified Sinotubular Junction

Objective Severe sinotubular junction (STJ) calcification presents important challenges during transcatheter aortic valve implantation, including risk of aortic dissection or aortic root rupture and valve malposition. We describe a straightforward and reproducible two-stage balloon inflation technique with a balloon-expandable SAPIEN 3 valve to optimize precision and procedural safety in this difficult setting. Technique Step 1: Initial balloon inflation at 2 mL less than nominal volume to secure annular anchoring and limit radial force on the calcified STJ. Step 2: Balloon advanced 1–2 mm under fluoroscopy toward the inflow and inflated to the full nominal volume, completing valve deployment. Pitfalls Inadequate anchoring may cause migration or embolization, underestimation of calcification can compromise expansion, and balloon overinflation may cause root injury. Conclusion This staged inflation method anchors the valve, minimizes STJ stress, and provides a simple, reproducible strategy that may improve safety in anatomically complex patients.