Abstract Body (Do not enter title and authors here): Background: Acute coronary obstruction (ACO) is a rare but potentially fatal complication of transcatheter aortic valve replacement (TAVR), particularly in patients with high-risk anatomy such as low coronary ostial height and narrow sinuses of Valsalva. Prophylactic coronary protection and real-time imaging are essential tools in safely managing these cases.
Case: A 62-year-old woman with severe aortic stenosis and multiple comorbidities—including prior stroke, COPD, and peripheral vascular disease—was referred for transfemoral TAVR. Preprocedural CT angiography demonstrated a systolic LM coronary height of 8.36 mm, placing her at high risk for ACO. A 23 mm Edwards SAPIEN 3 Resilia valve was successfully deployed under rapid ventricular pacing. Prophylactic left main protection was achieved by positioning a coronary guidewire via a 6 French guiding catheter from left femoral arterial access. After deployment, this coronary guidewire was jailed at the upper end of the sapient valve. Post-deployment angiography raised suspicion for left main compromise by the displaced left coronary cusp, visualized as a hazy filling defect.
Balloon angioplasty was performed using a 3.0 x 12 mm catheter, which resulted in partial improvement of angiographic appearance but did not fully resolve the haziness. IVUS catheter delivery initially failed but succeeded after introducing a second guidewire through the upper frame cell of the transcatheter valve. IVUS imaging revealed a preserved LM luminal area of >20 mm with no evidence of ostial narrowing or leaflet impingement. The jailed guidewire was safely removed without further intervention.
Decision-making: Despite equivocal angiography, IVUS provided definitive confirmation of LM patency and ruled out true obstruction. This guided the clinical decision to defer coronary stenting and pursue a conservative strategy. In contrast to cases requiring chimney stenting or BASILICA, this approach avoided permanent hardware and minimized procedural risk. This case illustrates the critical role of IVUS in clarifying ambiguous findings and enabling individualized management in anatomically high-risk TAVR.
Conclusion: Prophylactic LM protection, when paired with intravascular imaging, enables safe and tailored management of suspected ACO during TAVR. IVUS is essential in confirming patency and preventing unnecessary interventions in high-risk patients with ambiguous angiographic findings.