Background

Transcatheter aortic valve implantation (TAVI) has become a well-established treatment option for elderly patients with symptomatic severe aortic stenosis. Coronary artery anomalies (CAA) are a rare finding and reports of patients with coronary anomalies treated with TAVI are even more uncommon. Since CAA are infrequent per se, management of those patients with concomitant aortic stenosis is only derived from a few case reports. However, this clinical entity requires careful attention as it might be associated with an elevated risk of peri-interventional coronary obstruction.

Methods

We performed a systematic literature search in PubMed and Google Scholar for reports published on CAA in patients undergoing TAVI between 2011 and 2022. In addition, we screened our institutional database and retrospectively identified 20 consecutive patients with CAA treated with TAVI between 2016 and 2022. Patient and procedural data were analyzed regarding CAA type and course of the anomalous coronary artery, the choice of the transcatheter heart valve, whether coronary protection was done or not and if coronary obstruction did ultimately occur after TAVI. An algorithm for the management of patients with CAA has been derived from the published reports and our own experience.

Results

We identified 20 cases of CAA through literature research and 20 cases in our own institutional database. The pooled mean patient age was 80.6 ± 7.3 years and male sex represented 50%. The most common CAA in the total cohort was anomalous origin of a coronary artery from the opposite sinus (ACAOS) (75%, 30/40). Coronary protection with vessel wiring was done in 11 cases. Periinterventional coronary obstruction occurred in 5 (12.5 %) patients. In those cases, the trajectory of the anomalous artery was retro-aortic in 3 patients and interarterial in 2 patients. Protective measures had been taken in 4 of these patients. Management of coronary obstruction included coronary stent placement in 3 cases, transient extracorporeal life support in one case and emergency coronary artery bypass grafting in another case. TAVI was aborted in one case. There was no procedural mortality.

Conclusion

With a total of 40 cases, this is the largest body of evidence of patients diagnosed with aortic stenosis and CAA undergoing TAVI. Little is known about feasibility of TAVI in patients with CAA. In the absence of evidence-based clinical practice guidelines, a patient-tailored and risk-adapted approach is recommended. Awareness of this clinical scenario and meticulous preprocedural assessment together with protective measures could help minimize procedural complications.