Intentional Misalignment of a Transcatheter Aortic Valve to Preserve Reaccess to Coronaries of Anomalous Origin

Abstract

Achieving patient-specific commissural alignment of transcatheter aortic valves is particularly important to ensure coronary reaccess after transcatheter aortic valve implantation. Nevertheless, in case of uncommon origin of coronary arteries, commissural alignment could be counterproductive. This case shows how alignment techniques could serve to intentionally misalign the neocommissures in this subset of patients. ( Level of Difficulty: Intermediate. )

Transcatheter aortic valve implantation in patients with anomalous origin of a coronary artery

“…In cases of elevated risk of coronary obstruction some authors opted to implement precautions to increase peri‐interventional safety. The most common measure taken was to protect the coronary artery at risk with a 0.014 inch wire for rapid re‐access after THV implantation 4,5,7,9,11,12,15–17 . A guide catheter extension catheter was placed over the wire to disengage the larger coronary guide catheter during valve deployment in one case 12 .…”

“…1 Between 2011 and 2022, 17 publications including a total of 20 patients who had CAA and underwent TAVI were identified. [1][2][3][4][5][6][7][8][9][10][11][12][13][14][15][16][17] Each publication was analyzed regarding CAA type and course of the anomalous coronary artery, procedural characteristics including the choice of the transcatheter heart valve (THV), whether coronary protection was used or not and if coronary obstruction did ultimately occur after TAVI.…”

“…In 2011, Weich et al described for the first time a successful TAVI in a patient with malignant anomalous origin of the right coronary artery 1 . Between 2011 and 2022, 17 publications including a total of 20 patients who had CAA and underwent TAVI were identified 1–17 . Each publication was analyzed regarding CAA type and course of the anomalous coronary artery, procedural characteristics including the choice of the transcatheter heart valve (THV), whether coronary protection was used or not and if coronary obstruction did ultimately occur after TAVI.…”

“…12 Provisional balloon or stent placement was performed in five cases. 7,11,12,17 Coronary stent implantation was necessary in three of those cases and was performed without difficulty. 5,7,15 In all other cases when post implantation angiography showed sufficient coronary flow, the wire and/or balloon and stents were successfully removed from the coronary artery.…”

“…Costa et al described a case in which they intentionally misaligned the neo-commissures to prevent potential impairment of coronary reaccess. 17 Finally, careful attention should be given to bioprosthetic valve oversizing and high-pressure balloon inflation because it intuitively increases the risk for coronary compression. 5 An algorithm for the management of patients with CAA undergoing TAVI is proposed in (Figure 2).…”