Leaflet protrusion into left main coronary artery detected by intravascular ultrasound after transcatheter aortic valve implantation with SAPIEN 3

<span class="paragraphSection">An 83-year-old man was referred for management of symptomatic severe aortic stenosis. The heart team concluded that transcatheter aortic valve implantation (TAVI) using SAPIEN 3 was preferable because of his age and frailty. Preprocedural computed tomography showed a high left coronary ostial height and a sufficiently sized sinus of Valsalva. However, a left coronary cusp leaflet was longer than the left coronary height (we routinely perform this measurement) (<span style="font-style:italic;">A</span>). In this case, coronary protection with a guidewire was performed because a long leaflet can be a risk factor of coronary obstruction. Coronary angiography showed no atherosclerotic plaque in the left main coronary artery (LMCA) (<span style="font-style:italic;">B</span>). In aortography during predilatation with a 25-mm balloon, the leaflet tip seemed to have been dislodged close to the ostial LMCA, but coronary flow was maintained (<span style="font-style:italic;">C</span>). Then, a 29-mm SAPIEN 3 was deployed under rapid pacing. Post-deployment coronary angiography revealed a wedge-shaped filling defect in the LMCA (<span style="font-style:italic;">D</span>; Supplementary dataSupplementary data online, <span style="font-style:italic;">Movie S1</span>). Intravascular ultrasound (IVUS) was performed, and a mixed structure of high-echoic calcification and low-echoic soft tissue continuing from the mid-portion to outside of the LMCA was detected, indicating a native valve leaflet tip (<span style="font-style:italic;">E</span>; Supplementary dataSupplementary data online, <span style="font-style:italic;">Movie S2</span>). Blood pressure was maintained, while ST-depression was seen in V3-6. To prevent subsequent coronary events, a drug-eluting stent was implanted. No apparent defect of the LMCA was observed in the final coronary angiography (<span style="font-style:italic;">F</span>), and an IVUS image confirmed adequate stent apposition with the leaflet dislodged by the stent.</span>

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