Binder, Ronald K.

Falk, Volkmar

Frauenfelder, Thomas

Landmesser, Ulf

Lüscher, Thomas F.

Nguyen-Kim, Thi Dan Linh

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FundingP.M.R. is supported by investigator-initiated research grants from Astra-Zeneca, Novartis, AMGEN, and the NationalHeart Lung and Blood Insti-tutes (HL 101422, HL101389).Conflict of interest: P.M.R. has served as a consultant to ISIS, VascularBiogenics, Amgen, Pfizer, and Boston Heart, and is listed as a co-inventoron patents held by the Brigham and Women’s hospital that relate to theuse of inflammatory biomarkers in cardiovascular disease and diabetesthat have been licensed to AstraZeneca and Seimens. Neither P.M.R.nor the Brigham and Women’s Hospital receive royalty paymentsrelated to the use of these biomarkers in either the CIRT or CANTOStrials.ReferencesThe list of references is available in the online version of this paper.CARDIOVASCULAR FLASHLIGHT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .doi:10.1093/eurheartj/eht414Online publish-ahead-of-print 3 October 2013TAVI in a low left main coronary artery ostium and wide aortic sinusof ValsavaThi Dan Linh Nguyen-Kim1, Ronald K. Binder2, Thomas F. Lu¨scher2, Volkmar Falk3, Thomas Frauenfelder1and Ulf Landmesser2*1Department of Diagnostic and Interventional Radiology, University Hospital Zurich, Zurich, Switzerland; 2Cardiology, University Heart Center, University Hospital Zurich,Ramistrasse 100, CH-8091 Zurich, Switzerland; and 3Cardiac Surgery, University Heart Center, University Hospital Zurich, Zurich, Switzerland* Corresponding author. Tel: + 41 442559595, Fax: + 41 442554401, Email: ulf.landmesser@usz.chThis paper was guest edited by Brahmajee Nallamothu (bnallamo@umich.edu) University of Michigan.A very short distance between theaortic annulus and the left maincoronary artery (LMCA) ostium istypically a contraindication for trans-catheter aortic valve implantation(TAVI) given concerns of potentialcoronary obstruction followingtheir deployment. We report thecase of an 85-year-old patientadmitted to our hospital with acutecardiac decompensation. Transthor-acic echocardiography demon-strated severe aortic valve stenosis(aortic valve area: 0.7 cm2) and LVejection fraction of 40%. Coronaryangiography showed minimal coron-ary artery disease. The patient wasconsidered unsuitable for conven-tional cardiac surgery due to severalcomorbidities, however, a planningcomputed tomography for TAVI revealed an extremely low-lying LMCA (6.3 mm from the aortic annulus; Panels A and B) and calcified,bulky aortic valve leaflets [Panels B, C, and E (red asterisk)]. Because of repeated haemodynamic instabilities, we decided to firstperform a balloon aortic valvuloplasty with a guidewire and angioplasty balloon in place in the LMCA (Panel E) as a precaution against ob-struction. This was followed by TAVI with an Edwards-SAPIEN-XT 29 mm valvewithout anyobstruction noted due to awide aortic sinus ofValsalva (39 mm, Panels D and F ). No paravalvular leak was noted and the patient recovered rapidly.Coronary obstruction is a rare, but severe complication following TAVI. A short distance (,10 mm) between the aortic annulus andLMCA has been considered a contraindication in recent guidelines. In the first multi-centre registry of coronary obstruction followingTAVI, both the distance of the aortic annulus to the LMCA and the width of the aortic sinus of Valsalva were determined to be riskfactors. The present case illustrates that TAVI can be successfully performed in selected patients with a low LMCA and bulky, calcifiedaortic valve leaflets in the presence of a very wide aortic sinus of Valsalva, however, precaution with a guidewire and angioplasty balloonin place is recommended.R.K.B. is a consultant for Edwards Lifesciences, Inc., Irvine, CA, USA.Published on behalf of the European Society of Cardiology. All rights reserved.& The Author 2013. For permissions please email: journals.permissions@oup.comAnti-inflammatory therapies 1791

TAVI in a low left main coronary artery ostium and wide aortic sinus of Valsava

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