Late Sinus of Valsalva Sequestration After Transcatheter Aortic Valve Implantation in Native Aortic Valve

BACKGROUND: Coronary artery obstruction by sinus of Valsalva sequestration is a rare, life-threatening complication that occurs during or after the transcatheter aortic valve implantation procedure. CASE SUMMARY: An 82-year-old woman with severe symptomatic aortic stenosis underwent uncomplicated transfemoral transcatheter aortic valve implantation with a 23-mm Sapien S3 Ultra valve. Three months later, the patient presented to the hospital for chest pain and was found to have a non-ST elevation myocardial infarction. Diagnostic coronary angiography showed difficult left main coronary engagement despite the presence of thrombolysis in myocardial infarction (TIMI) grade 3 flow. Computed tomography angiography revealed a low-density filling defect within the left coronary sinus consistent with sinus sequestration causing partial left-system obstruction. Surgical revascularization (left internal mammary artery-left anterior descending artery and saphenous vein graft-obtuse marginal) with coronary artery bypass grafting was performed successfully. DISCUSSION: This case represents the second-only reported case of late sinus sequestration in a native aortic annulus. Risk factors include low coronary heights, narrow sinuses, and shallow sinotubular junction. Electrocardiography-gated cardiac computed tomography imaging remains crucial for diagnosis and for differentiating sinus insufficiency from sequestration. TAKE-HOME MESSAGE: Late coronary obstruction after transcatheter aortic valve implantation may occur due to sinus sequestration even in native valves; prompt computed tomography evaluation is critical for diagnosis and management.