Clinical Decision-Making in High-Risk Cross-Platform Redo-TAVI: Pre-Emptive Coronary Wiring and Chimney Stenting

Redo transcatheter aortic valve implantation (TAVI) in patients with prior transapical SAPIEN 3 valves carries a significant risk of coronary obstruction (CO). Chimney stenting is an established strategy to maintain coronary perfusion in high-risk valve-in-valve (ViV) procedures. We treated an 87-year-old cachectic woman with BMI of 16.9 kg/m2 who presented with cardiac decompensation due to severe restenosis of a 20 mm SAPIEN 3 valve implanted using a transapical approach in 2017. Computed tomography revealed index prosthesis frame extension beyond the sinotubular junction at the right coronary sinus, posing a risk of RCA occlusion. A staged transfemoral redo-TAVI using a 23 mm Medtronic Evolut FX+ valve was performed followed by deployment of the pre-positioned stent in the so-called chimney technique. The RCA guidewire and undeployed coronary stent were positioned in advance as a protective measure before valve deployment. During valve deployment, inferior ST-segment elevation occurred, prompting stent implantation in order to restore RCA patency. Angiography confirmed preserved coronary flow and optimal valve function. Careful preprocedural evaluation—including CT-based assessment of coronary height, sinus anatomy, and virtual valve modeling—is essential to minimize the risk of CO in ViV or redo-TAVI procedures. The chimney technique provides an effective bailout strategy for acute coronary obstruction, while procedural strategies such as commissural alignment and the cusp-overlap technique can optimize procedural and hemodynamic outcomes. Pre-emptive coronary protection using chimney stenting enables safe and effective redo transfemoral TAVI in patients with complex anatomy and prior transapical valve implantation, ensuring hemodynamic success and minimizing complications.