Transcatheter aortic valve implantation (tavi) with left main chimney protection and concomitant lad pci in an elderly high-risk patient: a case report

Abstract

Transcatheter aortic valve implantation (TAVI) carries a risk of left main (LM) coronary obstruction, particularly in elderly patients with low coronary height, small sinus of valsalva, or bulky calcified leaflets. Intracoronary imaging such as intravascular ultrasound (IVUS) may provide real-time anatomical assessment and aid in identifying patients at extremely high risk. At the Cardiovascular Centre, E hospital, we report the case of an 88-year-old woman with severe symptomatic aortic stenosis, stage IV chronic kidney disease, and frailty who underwent TAVI using a self-expanding Evolut FX valve. pre-procedural computed tomography revealed a very high risk of LM obstruction. immediately after valve deployment, IVUS assessment demonstrated that the displaced native aortic leaflet was located only 4,5 mm from the LM ostium, indicating a critical risk of obstruction despite preserved TIMI 3 coronary flow. Therefore, a prophylactic chimney stent was deployed from the LM into left anterior descending artery (LAD) to prevent delayed obstruction. Concomitantly, a severe LAD stenosis (90%) was treated with percutaneous coronary intervention. The patient remained hemodynamically stable, with excellent valve performance and patent coronaries at 7-day follow-up.

Conclusion: IVUS plays a crucial role in detecting the risk of LM obstruction after TAVI. Prophylactic chimney stenting is justified even when coronary flow is preserved that the anatomical risk is extremely high.