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Aortic valve stenosis is becoming the most common valvular heart disease, with an increasing incidence in most countries.1 Coronary artery disease is highly prevalent in patients with aortic stenosis and could be present in up to 50% of the cases.2 Treatment with percutaneous implantation of a trans-catheter prosthetic aortic valve (TAVI) now offer an effective alternative with and acceptable survival rate in high to moderate risk severe aortic valve stenosis.3 So physicians and interventional cardiologists in particular, will soon be confronted with patients with these implanted prosthetic-valves that will need coronary angiography or intervention because of progression of ischemic heart disease. We present a case of a patient with a previously implanted self-expandable aortic CoreValve ® (Medtronic Inc., MN, USA), in whom a coronary angiography was done because of an acute coronary syndrome. We review some of the technical aspects of the procedure in this situation and review the literature. A 68-year-old woman with severe symptomatic aortic stenosis and a high Euroscore, was treated successfully with TAVI using a CoreValve ® system. The pre-implantation coronary angiography at the time revealed no significant lesions. She remained asymptomatic and in NYHA Class I. Two years after valve replacement, she began with a typical progressive effort-related chest discomfort. The physical exam was normal, with a minor grade I ejective aortic murmur and a normal carotid pulse with adequate-amplitude. The troponin-I levels were elevated 10 times the reference values and the electrocardiogram showed sinus rhythm, left bundle branch block with no abnormal ST-segment changes and an episode of self-limited ventricular tachycardia. The echocardiogram revealed a functionally normal prosthetic valve with no insufficiency, moderate ventricular hypertrophy with normal ejection fraction and no regional motion abnormalities. With the diagnosis of a non-ST segment elevation acute coronary syndrome (NSTE-ACS), coronary angiography was performed using the right radial approach. A pigtail angiographic catheter was initially used. The prosthetic valve was easily crossed and no trans-valvular pressure gradient was seen. Angiograms of the proximal aorta and left ventricle were done with the standard technique. No aortic insufficiency was observed. For the coronary angiography, a Tiger ® (TIG) radial coronary catheter (Terumo Interventional systems) was used, and the left coronary artery was easily approached selectively through the prosthetic struts without any additional manipulation. The right coronary ostium could not be initially engaged with the same catheter even with the help of the guide-wire technique, but it was done directly with a JR4 Launcher ® coronary catheter (Medtronic Inc.) (Fig. 1). No significant lesions were appreciated in either coronary artery. The sinus and ostia were not compromised and the distal coronary flow was normal. No additional imaging or provocative test was done in this case. The diagnosis of NSTE-ACS without obstructive coronary disease was established, either because of micro-vascular disease or secondary to the documented arrhythmia. Trans-catheter aortic valve implantation is a new therapy for patients with aortic stenosis, with a trend to be used not only in high-risk cases but more broadly in the low to intermediate risk group.3 By 2015, more than 80,000 Corevalve ®

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Coronary angiography in a patient with a previously implanted trans-catheter aortic CoreValve®: Technical aspects, challenges and review of the literature