Very late left aortic sinus sequestration two years after TAVR: a case report

Introduction Aortic sinus sequestration is a rare late complication of transcatheter aortic valve replacement (TAVR) that may impair coronary access and coronary perfusion. Its diagnosis often requires multimodality imaging and careful clinical assessment. Case presentation A 72-year-old woman presented with disabling angina two years after TAVR performed for severe aortic stenosis using self-expanding aortic prosthesis. Resting electrocardiography and transthoracic echocardiography showed no abnormalities and confirmed normal prosthetic valve function. Coronary angiography failed to achieve selective catheterization of the left main coronary artery. Cardiac computed tomography (CT) subsequently confirmed sequestration of the left aortic sinus and demonstrated subclinical leaflet thrombosis (HALT) with pannus formation, without hemodynamic valve deterioration. No significant coronary artery disease was identified. After multidisciplinary Heart Team discussion, surgical aortic valve replacement was performed. Intraoperative findings confirmed the CT imaging results. The patient remained symptom-free at 3-month follow-up. Discussion This case illustrates a rare late complication of TAVR diagnosed through multimodality cardiac imaging and successfully managed through collaborative Heart Team decision-making. Multiple intricate factors contributed to this complication, including a high-risk anatomical predisposition, as well as subclinical valve thrombosis, valve degeneration, and frame endothelialization. This case also emphasizes the importance of meticulous pre-procedural screening before TAVR using a multiparametric assessment of coronary obstruction risk to facilitate long-term management and future coronary access.