Late Sinus of Valsalva Sequestration After Transcatheter Aortic Valve Implantation in Native Aortic Valve

Coronary artery obstruction by sinus of Valsalva sequestration is a rare, life-threatening complication that occurs during or after the transcatheter aortic valve implantation procedure.

An 82-year-old woman with severe symptomatic aortic stenosis underwent uncomplicated transfemoral transcatheter aortic valve implantation with a 23-mm Sapien S3 Ultra valve. Three months later, the patient presented to the hospital for chest pain and was found to have a non-ST elevation myocardial infarction. Diagnostic coronary angiography showed difficult left main coronary engagement despite the presence of thrombolysis in myocardial infarction (TIMI) grade 3 flow. Computed tomography angiography revealed a low-density filling defect within the left coronary sinus consistent with sinus sequestration causing partial left-system obstruction. Surgical revascularization (left internal mammary artery-left anterior descending artery and saphenous vein graft-obtuse marginal) with coronary artery bypass grafting was performed successfully.

This case represents the second-only reported case of late sinus sequestration in a native aortic annulus. Risk factors include low coronary heights, narrow sinuses, and shallow sinotubular junction. Electrocardiography-gated cardiac computed tomography imaging remains crucial for diagnosis and for differentiating sinus insufficiency from sequestration.

Late coronary obstruction after transcatheter aortic valve implantation may occur due to sinus sequestration even in native valves; prompt computed tomography evaluation is critical for diagnosis and management.