Extract

A very short distance between the aortic annulus and the left main coronary artery (LMCA) ostium is typically a contraindication for transcatheter aortic valve implantation (TAVI) given concerns of potential coronary obstruction following their deployment. We report the case of an 85-year-old patient admitted to our hospital with acute cardiac decompensation. Transthoracic echocardiography demonstrated severe aortic valve stenosis (aortic valve area: 0.7 cm2) and LV ejection fraction of 40%. Coronary angiography showed minimal coronary artery disease. The patient was considered unsuitable for conventional cardiac surgery due to several comorbidities, however, a planning computed tomography for TAVI revealed an extremely low-lying LMCA (6.3 mm from the aortic annulus; Panels A and B) and calcified, bulky aortic valve leaflets [Panels B, C, and E (red asterisk)]. Because of repeated haemodynamic instabilities, we decided to first perform a balloon aortic valvuloplasty with a guidewire and angioplasty balloon in place in the LMCA (Panel E) as a precaution against obstruction. This was followed by TAVI with an Edwards-SAPIEN-XT 29 mm valve without any obstruction noted due to a wide aortic sinus of Valsalva (39 mm, Panels D and F). No paravalvular leak was noted and the patient recovered rapidly.

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