Orthotopic Left Main Chimney Stenting to Prevent Stent Compression After Transcatheter Aortic Valve Replacement

Area of Science:

• Cardiovascular Medicine
• Interventional Cardiology
• Medical Imaging

Background:

• Severe aortic stenosis necessitates transcatheter aortic valve replacement (TAVR).
• Coronary obstruction (CO) is a serious complication post-TAVR, particularly with anatomical risk factors like a narrow aortic root.
• Preprocedural computed tomography (CT) is crucial for identifying patients at high risk for CO.

Observation:

• An 80-year-old woman with severe aortic stenosis underwent TAVR.
• Pre-TAVR CT identified a narrow aortic root and low coronary height, increasing CO risk.
• Post-TAVR, contrast staining and leaflet interaction with the left main (LM) ostium indicated impending obstruction.

Findings:

• Left main stenting was performed through a transcatheter heart valve (THV) cell due to a virtual THV-aorta space, preventing CO.
• This technique, termed orthotopic chimney stenting, proved feasible and effective.
• Postprocedural CT confirmed a well-expanded and patent LM stent.

Implications:

• Orthotopic chimney stenting through a THV cell is a viable alternative to conventional chimney stenting in narrow aortas.
• This approach may mitigate the risk of stent compression seen with classic chimney stenting in such anatomies.
• It offers a potential solution for preventing coronary obstruction in complex TAVR cases.