Coronary obstruction in transcatheter aortic valve-in-valve implantation preprocedural evaluation, device selection, protection, and treatment

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.6,7

Coronary 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.