Clinical Decision-Making in High-Risk Cross-Platform Redo-TAVI: Pre-Emptive Coronary Wiring and Chimney Stenting

Abstract

Background: Redo transcatheter aortic valve implantation (TAVI) in patients with prior transapical SAPIEN 3 valves carries a significant risk of coronary obstruction. Chimney stenting is an established strategy to maintain coronary perfusion in high-risk valve-in-valve (ViV) procedures. Case Description: An 87-year-old woman presented with NYHA class IV symptoms due to severe restenosis of a 20-mm SAPIEN 3 valve implanted in 2017. Computed tomography revealed stent extension beyond the sinotubular junction, posing a risk of right coronary artery (RCA) occlusion. A transfemoral redo-TAVI using a 23-mm Medtronic Evolut FX+ valve was performed with pre-positioned chimney stenting. During valve deployment, inferior ST-segment elevation occurred, necessitating immediate RCA stenting. A second distal RCA stent addressed residual stenosis. Final angiography confirmed preserved coronary flow and optimal valve function; Discussion: Careful preprocedural evaluation—including CT-based assessment of coronary height, sinus anatomy, and virtual valve modeling—is essential in high-risk ViV or redo-TAVI cases. The chimney technique provides an effective bailout for acute coronary obstruction, while procedural strategies such as commissural alignment and the cusp-overlap technique can optimize procedural and hemodynamic outcomes.; Conclusions: Planned coronary protection using chimney stenting enables safe and effective redo transfemoral TAVI in patients with complex anatomy and prior transapical valve implantation, ensuring hemodynamic success and minimizing complications.