An "Orthotopic" Snorkel-Stenting Technique to Maintain Coronary Patency During Transcatheter Aortic Valve Replacement

Coronary artery obstruction (CAO) during transcatheter-aortic-valve replacement (TAVR) represents a main concern for TAVR safety in patients with low coronary take-off. To date, "snorkel" (also called chimney) technique, consisting of stent implantation from the coronary ostium to the aorta within the space between the valve frame and the aortic wall, is the most adopted strategy to prevent CAO. This technique is associated with the creation of complex valve/stent configuration that can hinder repeat coronary interventions. Due to this concern, we set up an original sequence for coronary protection aiming to ensure a more physiological TAVR frame/stent configuration. According to this technique, TAVR prosthesis is released with a "protection" system consisting of guiding catheter (GC), wire and stent inside the coronary artery with high CAO risk. In the case of CAO occurrence, the stent is released according to the snorkel technique. In the absence of complete CAO, a new GC is advanced inside the implanted TAVR prosthesis and the stent is deployed from the coronary artery up to the prosthesis. We herein report two cases of very high CAO risk where this technique was successfully used during last-generation self-expandable prostheses implantation (in a native aortic valve and in one prosthetic aortic valve). In conclusion, this "orthotopic snorkel-stenting in TAVR" (OST) technique represents a novel option for treating impeding CAO during TAVR. As compared with the "classic" snorkel technique, it allows avoiding stent implantation in some patients (who do not experience CAO) and may provide a more predictable and physiologic TAVR prosthesis/stent configuration in the case of stent implantation need.