Acute obstruction of the right coronary ostium after Transcatheter Aortic Valve Replacement. Is it time to enhance coronary obstruction risk prediction?

Abstract Transcatheter aortic valve replacement (TAVR) is a well-established therapy for aortic stenosis, known for its safety and efficacy across a spectrum of patient risks compared to conventional aortic valve replacement (AVR). Despite its advantages, complications have been identified during or after the procedure. In a case involving a 72-year-old man with multiple comorbidities and severe aortic stenosis, pre-procedural planning revealed factors suggesting a higher risk for complications, such as calcifications in the ascending thoracic aorta, aortic valve, and left ventricular outflow tract (LVOT). The patient was considered at low risk for coronary obstruction. However, during TAVR with a 23 mm Sapiens 3 bioprosthesis, the patient experienced sudden dyspnea and chest pain. Coronary angiography revealed a contrast defect in the right coronary artery ostium, leading to immediate angioplasty, which was successful. While pre-procedural protection was deemed unnecessary in this case, it highlights the importance of considering factors beyond coronary height, such as calcium distribution and valve length, in predicting and preventing potential occlusion of coronary ostia during TAVR. Improved risk prediction is crucial in mitigating the occurrence of life-threatening complications.