Balloon aortic valvuloplasty with simultaneous aortic root injection: a case report of an adjunctive strategy to computed tomography for predicting coronary obstruction in transcatheter aortic valve-in-transcatheter aortic valve procedures.

Background: Computed tomography (CT) assessment is the standard for predicting coronary obstruction (CO) caused by sinus sequestration (SS) during transcatheter aortic valve (TAV) implantation in degenerated TAV (TAV-in-TAV) procedure, but it may not always be accurate. This report describes a prediction method for CO by using balloon aortic valvuloplasty (BAV) during TAV-in-TAV.

Case summary: An 87-year-old woman with a history of balloon-expandable transcatheter heart valve (BE-THV) implantation 7 years prior was admitted with worsening dyspnoea. Echocardiography revealed severe THV deterioration, and CT confirmed calcium proliferation in the THV. Our heart team decided to perform a TAV-in-TAV procedure using a 23-mm BE-THV. Preoperative CT imaging indicated an intermediate risk of CO. To evaluate CO risk more precisely, the top of a 20-mm balloon was positioned near the top of a BE-THV stent and inflated, followed by simultaneous aortic root injection (SARI). During SARI, contrast flowed into both coronary arteries, predicting a low risk of CO. Based on these findings, TAV-in-TAV was performed without coronary protection. The procedure was completed successfully without CO. After the procedure, the patient's symptoms improved, and echocardiography showed normal valve function. She was discharged without complications and remains under outpatient follow-up care.

Discussion: The diagnostic method for predicting CO using BAV with SARI could serve as a valuable adjunctive diagnostic tool in patients with an intermediate or high risk of SS anatomy after TAV-in-TAV. In such cases, this method may provide additional insights concerning precise CO risk and the indication of leaflet modification technique during TAV-in-TAV.