Expect the Unexpected, Acute Left Main Coronary Artery Occlusion During TAVI: A Case Series

Transcatheter aortic valve implantation (TAVI) is the gold standard therapy for high-risk patients with severe, symptomatic aortic valve stenosis, particularly in patients with impaired left ventricular systolic function or those with previous cardiac surgery. However, TAVI with non-dedicated devices in patients with native severe AR is challenging. Patients frequently have a bicuspid aortic valve, large dimensions of the aortic annulus, and a low aortic valve calcification load. These features increase the risk of significant paravalvular regurgitation and prosthesis migration. We present two cases of severe aortic valve regurgitation due to cusp migration of previously implanted surgical aortic valves and flail cusps. After discussion with the Heart team based on the patient's clinical profile and the high risk of surgical repair, self-expandable-TAVI was performed using the Navitor trans-catheter heart valve in the first case and the Accurate Neo 2 in the second case. During TAVI and before valve release, acute LM coronary artery occlusion was noted. Successful further TAVI implantation and PCI was a lifesaving strategy. The 3-month follow-up was uneventful. Transcatheter valve implantation expands its indications for more complex anatomy, off-label use in severe aortic regurgitation and patient's comorbidity. In the case of flail cusp during TAVI, LM coronary artery obstruction must be considered an expected complication, and LM protection maneuvers should be considered in difficult anatomies.