Sinus Sequestration After TAV-in-SAV: Optimizing CT Planning and Procedure

Sinus sequestration, well discussed in transcatheter aortic valve (TAV)-in-TAV, may also occur in TAV-in-surgical aortic valve (SAV), and its risk may be underrecognized if not assessed properly. We report an optimized TAV-in-SAV procedure in a patient at risk for sinus sequestration who was successfully treated after detailed computed tomography (CT) planning.

An 85-year-old woman who underwent previous surgical aortic valve replacement (Magna #19 valve, Edwards Lifesciences) presented with severe bioprosthetic stenosis. A TAV-in-SAV procedure was planned using an Evolut FX 23-mm valve (Medtronic) with optimization using a 20-mm balloon, which corresponds to the in vitro waist diameter of the Evolut FX 23-mm valve. Preprocedural CT, including maximum intensity projection (MIP) images, indicated a risk for sinus sequestration. A thorough CT assessment performed on the basis of this plan led to a successful optimized procedure.

Identifying sinus sequestration risk is crucial in TAV-in-SAV. MIP images on CT may help visualize the relationship between the neoskirt and the sinotubular junction. Optimizing TAV expansion is essential, and CT assessment should be conducted on the basis of the planned procedure.