Utilizing the en face view for unfavorable coronary access after transcatheter aortic valve replacement

Excerpt

An 88-year-old woman undergoing transcatheter aortic valve replacement (TAVR) using a 29-mm Evolut PRO+ (Medtronic, Minneapolis, MN, USA) (Fig. 1A) complained of chest pain. We suspected coronary artery disease and consequently planned a coronary angiography (CAG). Computed tomography revealed that the transcatheter heart valve (THV) commissure overlapped the left main coronary artery ostia, which was an unfavorable coronary access case because a catheter cannot cross the cells at the commissures of THV (Fig. 1B–D). We attempted a CAG using bi-plane fluoroscopic system of an en face (right anterior oblique, 63°; cranial [CRA], 49°) and perpendicular view (left anterior oblique, 50°; CRA, 20°) to show the short- and long-axis image of the THV, respectively. Using the en face view made it possible to cross a 5-Fr Judkins left 3.5 catheter through the cell posterior to the C-tab, which is a fluoroscopic marker for one of the THV commissures (Fig. 1E). Following this, we rotated the catheter clockwise anteriorly and were able to achieve selective engagement (Fig. 1F–H).

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