Left coronary artery obstruction during hybrid aortic valve implantation: anatomy, risk assessment, prevention and stenting

Due to the improvement of the technology of transcatheter aortic valve implantation (TAVI), the indications for this operation are extended. Clinical case of left coronary artery obstruction during TAVI, risk factors and prevention are described. Case description: A 64-year-old female patient with critical aortic stenosis. The risk of surgery with heart lung mashine according to EuroSCORE II - 5%, diabetes mellitus, previous stenting of left anterior descending artery. Severe atherosclerotic lesions of ilio-femoral arterial segments, calcification of the aorta and the angle between the long axis of aortic root and the longitudinal axis of left ventricle (LV) 42°. LVEDV - 74 ml (indexed LVEDV - 37 ml / m2). LV hypertrophy, EFLV - 65%. After transapical implantation of Med-Lab-CT 27 mm aortic valve, narrowing of left mainstem (compressed by calcified left coronary leaflet) occurred. Balloon dilatation and stenting of the left mainstem was performed. Conclusion: Obstruction of the left mainstem by the leaflet of the native calcified aortic valve occurs at the presence of low height of the orifice of the coronary artery, a narrow aortic root with a height of the Valsalva sinuses in the range from 7 to 12 mm, which creates limited space for the prosthesis, as well as bulky calcified formations on the native left or right valves.