Introduction
Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) is an established treatment for degenerated bioprosthetic valves in high-risk surgical candidates. Coronary obstruction (CO) is a rare but potentially fatal complication, with reported incidence of 2–3%, increasing to 7% in stentless or externally mounted leaflet prostheses such as the Trifecta™ valve (St. Jude Medical / Abbott). Risk factors include low coronary height, narrow sinuses of Valsalva, and short virtual valve-to-coronary (VTC) distances ≤3–4 mm.
Case
A 74-year-old woman with a degenerated 23 mm Trifecta™ aortic bioprosthesis presented with progressive dyspnea (NYHA III). Echocardiography confirmed severe prosthetic stenosis (Vmax 3.9 m/s, mean gradient 39 mmHg, AVA 0.8 cm²). CT analysis revealed left coronary artery height of 11mm and borderline VTC of 4 mm. ViV-TAVI with an Evolut™ FX Plus 26 mm valve (Medtronic) was performed transfemorally. Immediately after deployment, acute hypotension occurred due to left coronary obstruction by displaced Trifecta™ leaflet tissue. Emergency PCI with left main stenting (Xience® 4.5×15 mm, Abbott Vascular) restored TIMI III flow. Two days later, stent compression required re-stenting (Xience® Skypoint™ 5×12 mm, Abbott Vascular). Additionally, persistent iliac bleeding was managed with Via™ Bahn prothesis (Abbott Vascular). Despite successful revascularization, the patient developed bilateral posterior cerebral infarctions and died.
Discussion
This case highlights that even borderline VTC distances carry substantial risk of coronary obstruction. Preemptive coronary protection should be considered in anatomically high-risk ViV-TAVI cases. Although leaflet management techniques such as BASILICA or Chimney stenting are technically demanding and require operator experience, their systematic use can improve procedural safety.
Conclusion
Coronary obstruction remains a catastrophic event in ViV-TAVI, emphasizing the importance of careful CT-based planning, prosthesis-specific risk assessment, and preventive interventional strategies.
Keywords: Valve-in-Valve TAVI; Coronary obstruction; Trifecta™; Evolut™ FX Plus; Xience®; BASILICA; PCI
