Transcatheter Aortic Valve Replacement Requiring Modification of a Protruding RCA Stent

BACKGROUND: Protruding ostial stents represent a unique hazard for transcatheter aortic valve replacement (TAVR). CASE SUMMARY: An 81-year-old woman with symptomatic severe aortic stenosis and recent right coronary artery stenting with a 10-mm segment protruding into the aortic root presented for TAVR evaluation. After multidisciplinary discussion, the decision was made to proceed with TAVR with stent modification. The right coronary artery was wired through the stent struts at the distal end of the protruded segment and was ballooned, creating a neo-ostium. The protruded segment was crushed against the aortic wall using a valvuloplasty balloon. A balloon-expandable TAVR valve was deployed, with no coronary obstruction. DISCUSSION: This case represents a challenging TAVR procedure requiring a unique strategy to modify a protruding stent. TAKE-HOME MESSAGES: A structured sequence of: 1) neo-ostium creation (displacement of protruding stent segment); 2) balloon aortic valvuloplasty crush (aortic wall alignment); 3) controlled TAVR valve deployment; and 4) ostial optimization is reproducible.