FA

Patient is an 82-year-old female, hypertensive, diabetic, diagnosed breast cancer St II, post modified radical mastectomy, left and radiation therapy, admitted due to progressive dyspnea. Cardiac exam revealed distinct s1, soft s2, with grade 3/6 holosystolic murmur at the 2^nd intercostal space right parasternal border.She was diagnosed with Heart Failure secondary to Valvular Heart Disease (Severe Aortic Stenosis), NYHA Class III, Katz index score 1 EuroSCORE II 12.56%.

2D echoAortic stenosis, severe with estimated aortic valve area of 0.88 cm2 by continuity equation, indexed valve area of 0.63 cm/m2, dimensionless valve index of 0.21,peak gradient of 18.34 mmHg, and mean gradient of 11.71 mmHg. The left ventricular diameter is dilated with akinetic interventricular septum, anterior and anterolateral walls from base to apex. The calculated ejection fraction is 25.1 % by Simpson's method with Grade III left ventricular diastolic dysfunction. 

The left main coronary artery is a normal-sized vessel with non-significant stenosis at the ostium.The left anterior descending and circumflex arteries are normal-sized vessel that appears to be free of disease. The right coronary artery is a normal- sized dominant vessel with moderate (50-70%) stenosis of the mid right posterolateralbranch.

Transcutaneous Aortic Valve Implantation and Percutaneous Coronary Intervention of the Ostial Left MainBoth femoral artery was accessed via modified Seldinger Technique using 6F vascular sheath (Terumo) (1 sheath on the right, 2 sheaths on the left) Both femoral vein was accessed via modified Seldinger Technique using 6F and 5F vascular sheath (Terumo) 2 Pigtail 6Fr catheters (Cordis Infiniti) was parked at the non-coronary cusp and left ventricleA JL4 6Fr guiding catheter (Medtronic Launcher) was used to cannulate left mainA coronary wire (ASAHI Sion Blue) was parked at the distal left anterior descending artery A Temporary Pacemaker Wire(Biotronik) was advanced to the right ventriclePerclose devices (Abbott ProGlide) were inserted The 18Fr valve delivery sheath (MedtronicSentrant) was inserted Both pigtail catheters are then connected to manometry and pressures measuredNoted ST-Elevation in the cardiac monitor and hypotensive, injection was made to the guiding catheter and showed thrombus.Direct stenting with 4.0 x 16mm stent (Boston Promus Premier) was done in the ostial to mid segment and post dilate it with 4.0 x 8mm balloon (Boston NC Quantum Apex)A pigtail catheter was removed then Corevalve 29mm (Medtronic Evolut R) was deployed to the aorta All femoral sheaths were removed

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TAVI is the favored intervention for patients with severe aortic stenosis who have prohibitive surgical risk. Despite being less invasive than SAVR, TAVI still carries critical risks. One of dreaded intraprocedural complication is acute coronary obstruction. Coronary protection with preemptive wiring of the at-risk coronary ostia and eventual stent implantation is a strategy to prevent coronary obstruction. However, this strategy may carry a potential risk of thrombosis. Coronary artery thrombosis during TAVI is a rare occurrence, hence poorly studied. Endothelial injury or erosion from the wiring of the coronary artery can be a possible cause of thrombosis.