Transesophageal Echocardiographic Evaluation of Left Main Coronary Artery Stent Protection During Transcatheter Aortic Valve Implantation

94-year-old man with a history of severe symptomatic aortic stenosis, atrial fibrillation, hyper tension, and left main coronary artery disease presented for transcatheter aortic valve implantation (TAVI) via the transfemoral approach; written consent was obtained from the patient for presentation of this case. Given his age and comorbidities, a left main coronary stent was placed for his proximal left main coronary disease before TAVI. Technical considerations resulted in the stent protruding into the aortic root at the level of the sinotubular junction. Intraoperative transesophageal echocardiography (TEE) was performed using a Philips iE33 ultrasound system with an X7-2t TEE probe (Philips Healthcare, Andover, MA) revealing severe aortic valve (AV) stenosis (valve area 0.6 cm 2 by the continuity equation; mean gradient 44 mm Hg; peak gradient 78 mm Hg) with significant calcific degeneration and minimal motion of all 3 coronary cusps; mild aortic regurgitation was noted. The AV annular and sinotubular junction diameters were 23 mm and 25 mm, respectively. Mild-to-moderate tricuspid regurgitation, no mitral valve regurgitation, no significant left ventricu lar wall motion abnormalities, and left ventricular ejection fraction estimated as 66% were also noted. An echodense structure was visible in the aortic root at the level of the sinotubular junction in the midesophageal (ME) long-axis (LAX) view (Fig. 1 and Video 1, Loop 1, see Supplemental Digital Content 1, http://links.lww.com/AA/A478) and ME short-axis (SAX) view near the left coronary cusp (Video 1, Loop 2, Supplemental Digital Content 1, http://links. lww.com/AA/A478); it was also visible with fluoroscopy and consistent with a left coronary ostial stent protruding approximately 0.5 cm into the aortic root. Two-dimensional color-flow Doppler interrogation demonstrated flow through the stent, and real-time 3-dimensional TEE imaging provided additional confirmation of stent protrusion (Fig. 2A). Because the implanted bioprosthetic AV is deployed within the native AV extending below and above the