A Combined Strategy for TAVR in High-Risk Anatomy: Small Ventricle and Low Coronary Ostia

Transcatheter aortic valve replacement (TAVR) in patients with a critically small left ventricle (LV) carries risks of hemodynamic collapse ("suicide LV") and coronary occlusion.

A 73-year-old woman with severe aortic stenosis, marked LV hypertrophy, and a tiny LV cavity (LV end-diastolic diameter 29.3 mm) faced imminent bilateral coronary occlusion because of low ostia and small sinuses. We used aggressive volume loading to maintain preload and a prophylactic bilateral chimney stenting strategy. A 23-mm self-expanding bioprosthesis was successfully implanted with the chimney stents, preserving coronary perfusion. Postprocedural echocardiography showed excellent valve function with minimal paravalvular leak, and the patient recovered without complications.

This case underscores the necessity of managing both intraventricular space constraints and extreme coronary risks simultaneously. The double-chimney approach provided robust protection where anatomic reserves were absent.

For TAVR candidates with a critically small LV and high-risk coronary anatomy, a unified protocol combining volume optimization and prophylactic bilateral chimney stenting ensures procedural safety and success.