Precision Management of High-Risk Coronary Obstruction During TAVR Using a Physiology-Guided Strategy.

BACKGROUND

Coronary artery obstruction is a rare but devastating complication of transcatheter aortic valve replacement (TAVR). Prophylactic chimney stenting is a bailout strategy but carries long-term risks.

CASE SUMMARY: A 72-year-old woman with severe aortic stenosis and high-risk coronary artery obstruction anatomy (low left coronary ostium height of 9.1 mm, redundant calcified leaflet) underwent TAVR. Angiography after valve deployment showed ambiguous left coronary leaflet displacement with delayed contrast clearance. However, immediate and dynamic fractional flow reserve (FFR) assessments consistently remained above the ischemic threshold (>0.80) despite aggressive balloon postdilations. Consequently, chimney stenting was safely deferred. The patient was asymptomatic at the 3-month follow-up.

DISCUSSION: Relying solely on anatomical predictors may lead to overtreatment. Physiological assessment using FFR effectively defines the functional significance of anatomical proximity, safely avoiding unnecessary permanent implants.

TAKE-HOME MESSAGE: Dynamic FFR monitoring differentiates anatomical proximity from true functional ischemia during TAVR, safely guiding the avoidance of unnecessary chimney stenting.