Coronary Alignment With a Balloon-Expandable Valve in a Coronary Artery Anomaly

Commissural and coronary alignment during transcatheter aortic valve replacement (TAVR) has been a highly useful technique for improving the function of bioprosthetic valves and facilitating future coronary reaccess; however, coronary alignment is still not well established in BEV, especially with Edwards Sapien valves.

We present a 79-year-old woman with severe aortic stenosis and an anomalous origin of the right coronary artery. She underwent TAVR with an Edwards Sapien 3 Ultra valve. During the planning of the procedure, commissural alignment simulation indicated severe overlap between the neocommissure and the right coronary artery. Therefore, coronary alignment was planned. With computed tomography support, we performed crimping using the "neocommissural inversion" technique to achieve the proper position of the neocommissure in the annular plane. Postprocedural computed tomography revealed a significant reduction of overlap in both coronary ostia.

This case underscores the importance of meticulous preprocedural planning and the application of advanced imaging techniques to achieve optimal coronary alignment in patients with complex coronary anatomy undergoing TAVR.