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A-72-y-old man was referred fromanother hospital due to progressive dyspnea with NYHA FC III Severe AS was diagnosed. Past Medical HxHTNCKD stage IV (Cr 3.96 mg/dl)STS score = 7.1Frailty score = 5

CXR: CardiomegalyNon contrast MDCT of whole aorta: Trileaflet aortic valve with severe aortic stenosis(estimated AV area 51 mm2) Annulus 20 mm Aortic sinus 28 mm STJ 21 mm Perimeter 74 mm area 426 mm2 right coronary height  9 mm left coronary height 11 mm The narrowest diameters of right external artery 7.3x8 mm and left exteranal artery 7x7.6
TAVI - coronary occlusion - Echo pre TAVI- 1 - PSLAX.avi

Pressure gradient across AV = 60 mmHg

Transfemoral TAVR with conscious sedation was done. Evolut R size 26 was successful implanted.  After valve replacement and closure right groin with 2 proglides for 10 min, the patient developed VF with cardiac arrest. CPR was started x 25 min then ROSC. TTE showed significant impaired LV contraction with SEC. Aortogram showed totally occlusion of both RCA and LCA. Snare size 30 retrieved valve into ascending aorta. Second Evolut R valve size 23 was replaced. Post TAVR pressure gradient showed 18 mmHg LVEDP was 20 mmHg
TAVI - coronary occlusion - 21 - AO gram.avi
TAVI - coronary occlusion - 28 - Snare valve.avi
TAVI - coronary occlusion - 45 - final angio.avi

Don't believe in unreliable data.In small SOV and borderline coronary height: high risk for coronaryocclusion, carefulto select valve size In coronary occlusion, snare the valve out is the fastest way to safe the patient.