https://orcid.org/0000-0002-6603-1403
An 82-year-old woman with severe aortic stenosis and moderate aortic regurgitation underwent transcatheter aortic valve replacement (TAVR). Pre-procedural computed tomography (CT) revealed a type D quadricuspid aortic valve (QAV) with a slightly smaller right sinus of Valsalva and lower coronary height in the right coronary artery (RCA), raising concerns about coronary occlusion (Figure 1A–D). QAV might have a longer leaflet height and shallower cusp depth than a tricuspid aortic valve, increasing coronary occlusion risk even without other risk indicators based on our prior encounter with a patient with type A QAV who experienced unexpected coronary occlusion immediately after a SAPIEN 3 valve replacement. We created a three-dimensional (3D) model from the CT data using Materialise Mimics inPrint software and simulated the RCA occlusion risk using a 23 mm balloon corresponding to the SAPIEN 3 valve. Valve size choices were based on annulus area measurements. Despite our concerns, the simulation predicted no occlusion (Figure 1E, Supplementary data online, Video S1). We protected the RCA, considering possible uncertainties in TAVR with QAV. Consistent with simulation results, no coronary obstruction occurred (Figure 1F–H, Supplementary data online, Videos S2 and S3). However, the valve overlap with the RCA ostium in Figure 1H necessitates vigilant monitoring for delayed coronary occlusion. Even without occlusion, we noted possible contributions of morphological differences between types A and D QAV, underscoring the importance of considering individual valve morphologies during the precise risk assessment of TAVR procedures involving QAV. Therefore, 3D simulations may be useful for risk assessment in complex TAVR procedures, including QAV.
The patient’s imaging findings. (A) Pre-procedural computed tomography shows QAV. (B and C) Right and left coronary ostia heights (10.8 and 12.8 mm), right and left leaflet lengths (12.2 and 15.2 mm), and the fulcrum of the right and left leaflets to the coronary artery (cusp depth) (3.6 and 3.8 mm). (D) Annulus perimeter and area: 67.3 mm and 354.1 mm2, respectively. (E) Three-dimensional model simulations predicted no occlusions. (F–H) No coronary obstruction occurred. LCC, left coronary cusp; NCC, non-coronary cusp; QAV, quadricuspid aortic valve; RCA, right coronary artery; RCC, right coronary cusp.
Supplementary data
Supplementary data are available at European Heart Journal – Imaging Methods and Practice online.
Consent: The patient’s consent was obtained for the publication of this clinical vignette.
Funding: none declared.
Data availability: The data underlying this article are available in the article.
Lead author biography
Dr Yusuke Oba graduated from Faculty of Medicine, University of Miyazaki, in 2008. He holds a doctorate degree in Medicine from Jichi Medical University. He is currently a lecturer of Cardiovascular Medicine, Jichi Medical University School of Medicine.
Author notes
Conflict of interest: none declared.
