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.