Bailout From Sinus Jailing: In-Series TAVR-in-TAVR to Avoid Coronary Flow Obstruction

Abstract

Redo transcatheter aortic valve replacement (TAVR) may pose the risk of coronary flow obstruction. We report 2 cases of severe TAVR regurgitation due to different physiopathological mechanisms in which TAVR-in-TAVR could be at high risk for sinus sequestration. Both cases were successfully treated by in-series implantation of a second transcatheter heart valve, thus avoiding sinus sequestration. (Level of Difficulty: Intermediate.).

Keywords: CT, computed tomography; PVL, paravalvular leak; STJ, sinotubular junction; TAVR, transcatheter aortic valve replacement; TAVR-in-TAVR; THV, transcatheter heart valve; coronary obstruction; durability; transcatheter aortic valve replacement.

Graphical abstract

Figure 1

Procedural Planning and Post-Procedural Evaluation in Case 1 (A) Pre-TAVR CT scan showing TAV commissure level (red dashed line) above the STJ (yellow dashed line) in both the left coronary sinus (LCS) and right coronary sinus (RCS). (B) Distance between the THV (red dashed line) and STJ is only “virtual” in both LCS and RCS. (C, D) Schematic illustrations of procedural planning. Red × and green × indicate first and second implanted THV commissure level, respectively. (E to G) Post-TAVR CT scan confirming coronary patency (E) and in-series leaflet positions and patency of both the left coronary artery (LCA) and right coronary artery (RCA) (F, G). Red × indicates ACURATE neo leaflets. Green × indicates MyVal leaflets. CT = computed tomography; STJ = sinotubular junction; TAV = transcatheter aortic valve; TAVR = transcatheter aortic valve replacement; THV = transcatheter aortic heart valve.

Figure 2

Procedural Planning and Post-Procedural Evaluation in Case 2 (A) Pre-TAVR CT scan showing a TAV commissure level (red dashed line) above the STJ (yellow dashed line), particularly in the right coronary sinus (RCS). (B) Distance between the THV (red dashed line) and STJ is 0.2 mm in the RCS, but is acceptable (>2.0 mm) in the LCS and noncoronary sinus. (C, D) Schematic illustrations of procedural planning. Red andgreen × indicate first and second implanted THV commissure level, respectively. (E to G) Post-TAVR CT scan confirming coronary patency (E) and in-series leaflet positions and patency of both the left coronary artery (LCA) and right coronary artery (RCA) (F, G). Red × indicates Evolut R leaflets. Green × indicates Lotus leaflets. Abbreviations as in Figure 1.