Images in Cardiovascular Medicine
Sinus Sequestration as a Complication of Transcatheter Aortic Valve-in-Transcatheter Aortic Valve for Valve Embolization
2025 Volume 89 Issue 4 Pages 518-
Details
2025 Volume 89 Issue 4 Pages 518-
Sinus sequestration (SS) is a significant complication of transcatheter aortic valve (TAV)-in-TAV, especially in patients with a narrow sinotubular junction and/or low Valsalva height, although actual cases are rarely reported.
We performed TAV implantation in an 81-year-old woman with severe aortic stenosis (annulus: 71.5 mm). We implanted a 25-mm Navitor valve (Abbott) at a 3-mm depth (Figure A–C). During nose cone retraction, the valve migrated upward and embolized (Figure D). The patient experienced hemodynamic collapse without pericardial effusion, atrioventricular block or coronary obstruction (Supplementary Movie 1). Acute aortic regurgitation due to the displaced leaflet was diagnosed (Supplementary Movie 1, Figure D). Without snaring the valve, because of the hemodynamic instability, we implanted a 23-mm SAPIEN3UltraRESILIA valve (Edwards Lifesciences) as a bailout with left coronary artery (LCA) protection (Supplementary Movie 2). Despite temporary improvement, the patient suffered cardiac arrest, necessitating extracorporeal membrane oxygenation. LCA angiography revealed left SS (Figure E). Blood pressure increased following ostial LCA ballooning, and 2-ply drug-eluting stents were implanted from the LCA into the first valve (Figure F–H). The patient was discharged home without significant sequelae after 1 month of hospitalization.
Bailout from sinus sequestration. Confirmation of implantation depth from (A) double cusp view and (B) left anterior oblique view. (C) Detached valve from left anterior oblique view. Coplanar view of (D) embolized valve, (E) left coronary angiography and (F) stenotic sinotubular junction. (G) Stenotic sinotubular junction on intravascular ultrasound. (H) Final aortography from coplanar view. Dotted line, annular line; asterisk, lifted leaflet; arrowhead, transducer; curved dotted line, coronary stent.
Although SS is widely simulated using computed tomography, real-life cases remain limited in number. Before TAV-in-TAV is performed,1 it is crucial to assess SS risk based on the first valve’s position and aortic root size, and modify the leaflet and/or protect the coronary artery, if necessary.
R.H. is a clinical proctor of Edwards Lifesciences, and I.T. is an onsite proctor of Edwards Lifesciences, Medtronic and Abbott.
Supplementary Movie 1. Left coronary angiography after valve embolization.
Supplementary Movie 2. Valve-in-valve procedure.
Please find supplementary file(s);
https://doi.org/10.1253/circj.CJ-24-0933
