Coronary Obstruction in Transcatheter Aortic Valve-in-Valve Implantation

The majority of surgical heart valves being implanted during the past decade are bioprosthetic, tissue valves with limited durabiity.1–4 These tissue valves have limited durability.2–4 Recently, implantation of transcatheter valves inside failed surgically implanted aortic bioprostheses (valve-in-valve [VIV]) has been reported as a less-invasive alternative to repeat surgery.5 Although procedural success is achieved in the great majority of patients, this therapy is associated with several potential risks, including ostial coronary occlusion.6,7Coronary obstruction is a serious procedural complication, associated with a high mortality rate.5–9 Importantly, during the recent years, several preprocedural and technical aspects have been described to identify those patients at increased risk. Therefore, in such high-risk patients, a modified VIV procedure, redo surgical valve replacement, or medical treatment only may be considered (Figure 1). We herein review the mechanisms of coronary obstruction, the optimal identification of patients at risk for coronary obstruction, and further describe technical considerations for preventing and treating this life-threatening complication.Figure 1. Flow chart of suggested evaluation and treatment of a candidate for aortic Valve-in-Valve implantation. (1) Details in Tables 1 to 3. (2) According to imaging and clinical characteristics. (3) Balloon valvuloplasty will optimally model the risk for coronary occlusion using a balloon size similar to the transcatheter heart valve (THV) device to be implanted. The risk for hemodynamic instability after valvuloplasty secondary to worsening regurgitation should be considered, and a THV device should be prepared for rapid implantation if needed. (4) If the patient is hemodynamically stable after valvuloplasty and the risk for left main occlusion seems high, considerations for redo surgery or medical treatment only could be made, otherwise coronary protection is advocated using a wire and a stent. (5) Consider using a retrievable THV device or a device with …