TRANSCATHETER Aortic Valve Implantation with Anomalous Left Main Origin From Right Coronary Cusp: A Case Report

Introduction

Transcatheter aortic valve implantation (TAVI) is a minimally invasive procedure in which a new aortic valve is inserted within a stenotic native valve to restore effective cardiac blood flow. It has emerged as a transformative approach for the treatment of severe aortic stenosis, particularly in patients who are not suitable candidates for surgery [1]. However, this procedure presents distinct challenges when associated with rare congenital cardiac anomalies, such as an anomalous origin of the left main (LM) coronary artery from the right coronary cusp (RCC) [2]. The presence of an LM artery originating from the RCC is an uncommon congenital condition that can considerably affect procedural strategy and safety due to the risk of coronary obstruction or compromise during valve deployment. In patients with anomalous coronary anatomy, TAVI may lead to complications, including coronary obstruction, vascular access difficulties, valve malposition, increased procedural complexity, conduction abnormalities, and hemodynamic instability [3].

The rarity of this anatomical configuration among TAVI candidates underscores the importance of the present case. Existing literature concerning TAVI management in the presence of such coronary anomalies remains limited, highlighting a knowledge gap in both preprocedural evaluation and intraoperative coronary protection strategies [1]. This case provides valuable insights into the procedural adjustments necessary for successful outcomes in patients with anomalous coronary anatomy – such considerations are not addressed in current clinical guidelines.

Moreover, this report enriches the limited body of evidence on TAVI in patients with coronary anomalies, offering a reference for cardiologists who encounter similar cases. The report emphasizes the need for early recognition of this rare anomaly, demonstrates the adaptability required in interventional cardiology, and outlines lessons that may improve procedural safety and patient outcomes in future interventions.

Case Report

INITIAL ASSESSMENT AND DIAGNOSTIC EVALUATION:

Laboratory evaluation showed normal complete blood count and biochemistry results. Electrocardiography revealed normal sinus rhythm with a PR interval of 158 ms and a QRS duration of 121 ms. Her body mass index was 42 kg/m², and her body surface area was 1.93 m².

ECHOCARDIOGRAPHY:

Echocardiography revealed pronounced aortic valve calcification with restricted leaflet motion. The valve was well visualized; measurements indicated severe aortic stenosis, with a peak gradient of 64 mmHg, mean gradient of 39 mmHg, and dimensionless velocity index of 0.24. The aortic valve area was critically reduced to 0.58 cm2 (normal range: 3–4 cm2), accompanied by mild aortic regurgitation. Both ventricles demonstrated normal size and function, without evidence of pericardial effusion (Figures 1–3).

Given the patient’s clinical presentation and echocardiographic findings, this case was reviewed at a multidisciplinary Heart Team meeting and subsequently discussed at an Advanced Intervention Procedure meeting. Considering her age and comorbidities, the patient was accepted for TAVI.

CARDIAC CT FINDINGS:

As part of the preprocedural assessment for TAVI, cardiac computed tomography (CT) was performed to determine precise aortic valve measurements. Cardiac CT revealed an anomalous origin of the LM coronary artery from the RCC with a transseptal, nonmalignant course. The LM segment within the septum demonstrated 2 eccentric calcified plaques causing less than 50% luminal stenosis (Figure 4).

Cardiac CT further delineated cardiac anatomy relevant to TAVI planning. The aortic annulus was moderately sized, with a short diameter of 19.9 mm and long diameter of 24.0 mm. The annular area measured 353 mm2, with a circumference of 71.2 mm. The distance from the annulus to the LM coronary artery was 7.1 mm; from the annulus to the right coronary artery at the sinus of Valsalva, the distance was 7.2 mm. Sinus-to-commissure diameters measured 26×26×28 mm, and sinus-to-sinus diameters measured 22×24×27 mm (Figure 5).

Additional imaging showed a left ventricular outflow tract diameter of 18.7 mm, measured 1 cm below the annulus. Sinotubular junction dimensions were 24.2×24.6 mm, with distances from the annulus to the sinotubular junction measuring 14.3 mm on the left and 14.6 mm on the right. Procedural planning was further guided by calculated imaging angles: a coplanar angle of 37° in the left anterior oblique projection and 29° cranial, with cusp overlap projection angles of 21° right anterior oblique and 19° caudal. The membranous septum was located 3.8 mm below the annulus, providing additional guidance for optimal valve positioning.

CARDIAC CATHETERIZATION FINDINGS:

Cardiac catheterization confirmed the anomalous coronary origin identified on CT and showed no evidence of obstructive coronary artery disease (Figure 6).

TAVI PROCEDURE:

The TAVI procedure was performed via a transfemoral approach, incorporating 2 coronary protection techniques before valve deployment. The first technique involved advancing a guidewire through the anomalous LM coronary artery to allow immediate percutaneous coronary intervention if complications occurred (Figure 7).

The second technique involved balloon inflation within the aortic valve to assess the potential for obstruction of the anomalous LM coronary artery. The test showed no obstruction, and the LM artery remained patent after balloon inflation (Figure 8).

After the successful balloon trial that confirmed safety for the LM artery, the transcatheter valve was advanced into position and fully deployed within the aortic annulus (Figure 9). Post-deployment assessment demonstrated that all coronary arteries remained patent (Figure 10).

POST-TAVI:

The patient experienced substantial improvement in dyspnea, with NYHA functional class improving from III to I. Postprocedural echocardiography showed considerable reductions in aortic valve gradients, with a peak gradient of 23 mmHg and mean gradient of 12 mmHg; there was no evidence of aortic regurgitation. The hospital course was uneventful, and the patient was discharged the following day. At her 3-month outpatient follow-up, she remained clinically stable with NYHA class I symptoms and no new complaints.

Discussion

CONTRIBUTIONS TO MEDICAL KNOWLEDGE:

This case highlights the need for improved preprocedural imaging, refined procedural strategies, and specialized clinician training. It underscores the efficacy of TAVI in optimizing outcomes for anatomically complex patients and may inform the evolution of clinical guidelines and future research in this area.

Conclusions

This case reinforces the feasibility of performing TAVI in patients with severe aortic stenosis and anomalous coronary anatomy. It emphasizes the critical role of detailed preprocedural imaging and planning in achieving successful outcomes. The findings contribute valuable insights to the growing literature concerning the management of high-risk patients with coronary anomalies and will support continued research and case reporting to better define optimal strategies for this unique population.