Landmark-based low implantation using a balloon-expandable valve to avoid sinus sequestration during redo transcatheter aortic valve implantation: a case report

Redo transcatheter aortic valve implantation (TAVI) is increasingly performed for structural valve deterioration of transcatheter heart valves. Sinus sequestration is a mechanism of coronary obstruction in which displaced leaflets of the index transcatheter valve isolate the coronary sinus from the aortic root after redo TAVI.

An 82-year-old woman presented with dyspnoea due to structural valve deterioration 5 years after implantation of a 23-mm SAPIEN 3 (Edwards Lifesciences, Irvine, CA, USA) valve. Computed tomography demonstrated bilateral high-risk anatomy for sinus sequestration during redo TAVI. Coronary ostia and the sinotubular junction were located below the estimated neo-skirt plane. The virtual transcatheter valve-to-sinotubular junction distance was 0 mm, and the virtual transcatheter valve-to-coronary distances were 3.7 and 4.7 mm for the right and left coronary arteries, respectively. To preserve residual sinus space, a landmark-based low implantation strategy was planned using the lower border of the uppermost cell of the index SAPIEN 3 valve as a fluoroscopic landmark. A second 20-mm SAPIEN 3 Ultra RESILIA (Edwards Lifesciences) valve was implanted with its upper edge aligned to this landmark. Final angiography demonstrated preserved coronary flow without sinus sequestration, and intravascular ultrasound confirmed preserved sinus space outside the displaced leaflet complex in both coronary sinuses. No conduction disturbances or procedural complications occurred.

Landmark-based low implantation using the uppermost cell of the index transcatheter valve may represent a useful strategy to preserve sinus flow and avoid sinus sequestration during redo TAVI in selected high-risk anatomies.