In-Situ Observation of Incomplete Left Main Trunk Obstruction After Valve-in-Valve Transcatheter Aortic Valve Implantation

Coronary ostial obstruction or sinuses of Valsalva sequestration is rare but a potentially life-threatening complication of transcatheter aortic valve implantation that results from the complex interactions between the native coronary artery, native aortic root, and components of prosthetic valves. A comprehensive understanding of the design and alignment of surgical valves, together with detailed preoperative imaging and measurement, is crucial for its prevention. We herein share rare in-situ and computed tomographic images of a valve-in-valve complicated with incomplete obstruction of the left main trunk (Figures 1,2) in a human heart rejected for transplantation.

Figure 1.

Valve-in-valve complex.

Figure 2.

Computed tomographic analysis.

The aortic root viewed from the sinutubular junction reveals a space beside the post of the surgical valve (Carpentier-Edwards PERIMOUNT Magna Ease aortic valve 25 mm, Edwards Lifesciences, Irvine, CA, USA) (sky-blue arrow), which allows communication between the left main trunk and ascending aorta, preventing complete obstruction (Figure 1A). Asymmetrical expansion/underexpansion due to oversizing and resultant leaflet bending is also noted (Figure 1A). Light sources in the left (Figure 1B) and right (Figure 1C) coronary arteries confirm the left main trunk covered with the surgical leaflet, while the right coronary artery is barely covered. The inner skirt of the transcatheter valve (SAPIEN3 26 mm, Edwards Lifesciences) is below both orifices (Figure 1B,C). Profile images of orifices of the left (Figure 1D) and right (Figure 1E) coronary arteries also confirmed their relationships to the surgical valve leaflets. The surgical valve is fully covered by the stent frame of the transcatheter valve (Figure 1F). The sinuses of the Valsalva wall are removed to expose the surgical valve leaflet outside the transcatheter valve. The plane of the free margin of the surgical valve leaflet (risk plane) is nearly identical to the plane of the stent post of the surgical valve.

Risk plane defined at the height of the surgical valve leaflet is higher than the superior margin of the left main trunk (Figure 2A), lower than that of the right coronary artery (Figure 2B). Thus, the left main trunk is covered by the surgical valve leaflet (Figure 2A,C) with a lateral space (asterisks) communicating with the ascending aorta (Figure 1A), preventing complete obstruction. The right coronary artery is not fully covered by the surgical valve leaflet (Figure 2B,D). Transcatheter valve to coronary distance is 4.4 mm for the left main trunk (Figure 2C) and 1.3 mm for the right coronary artery (Figure 2D). Leaflet to coronary distance is 2.8 mm for the left main trunk. Tip of the stent posts of the surgical valve are located at the level of the right coronary artery (Figure 2D), with shorter distances to the sinuses of Valsalva wall on the right and left coronary aortic sinuses (Figure 2D). The surgical valve is fully covered by the stent frame of the transcatheter valve (Figures 1F,2E).

Acknowledgments

We thank the donor for the advancement of education and research. We are grateful for the supports from the One-Legacy Foundation, the National Institutes of Health (P01 HL164311 to K.S.), and the UCLA Amara-Yad Project. We appreciate Dr. Olujimi A. Ajijola for establishing the human heart research pipeline and Ms. Amiksha S. Gandhi for her support of this project.

Conflicts of Interest

None.

Funding

NIH grant P01 HL164311 to K.S. and the UCLA Amara-Yad Project.