Leaflet length and left main coronary artery occlusion following transcatheter aortic valve replacement

Coronary artery occlusion during transcatheter aortic valve replacement is a rare complication. However, it is a very severe and life-threatening event. Although there are some possible causes of this phenomenon, definite etiologies and predictors are unknown because of the small number. We describe one case of left main coronary artery occlusion immediately after deployment of a prosthetic valve. The patient became hypotensive and developed cardiopulmonary arrest. However, the coronary artery was successfully stented with a help of cardiopulmonary bypass and he recovered well. In this case, pre-procedural computed tomography (CT) showed the adequately high coronary height and no other significant conventional predictor for coronary occlusion. The examinations were retrospectively reviewed and the CT showed a long leaflet compared to the coronary sinus complex. The fluoroscopy appeared to show the long leaflet covering the left main coronary artery ostium immediately after the valve deployment. The height of the coronary artery ostium from the aortic annulus appeared sufficiently high in this case and did not explain the coronary compromise; leaflet length in relation to the coronary sinus dimension seemed more relevant. The ratio between leaflet length and curved coronary sinus height (L/C) may be one novel predictor for coronary artery occlusion.