Chimney/snorkel stenting during TAV-in-TAV: bedside to bench

A 92-year-old female with prior transcatheter aortic valve implantation (TAVI) with a 26 mm CoreValve bioprosthesis (Medtronic) was admitted for worsening dyspÂnoea, home oxygen requirement, and a mean gradient of 39 mmHg, six years after the TAVI procedure. Transoesophageal echocardiography and computed tomography (CT) imaging showed no leaflet thrombosis but a severely calcified and degenerated transcatheter aortic valve (TAV).

Given her age and comorbidities, the patient was deemed to be at prohibitive risk for surgery. CT scans showed a high risk for sinus sequestration during TAV-in-TAV due to a low and narrow sinotubular junction (Figure 1A). Commissural misalignment of the initial TAV prohibited leaflet modification treatments. A Heart Team decision was made for chimney stenting (also called snorkel stenting) in both coronaries to preserve coronary patency. TAV-in-TAV was performed using a 23 mm SAPIEN 3 (S3) valve (Edwards Lifesciences) with the S3 outflow at CoreValve node 4 (Moving image 1). Chimney stenting successfully maintained coronary patency (Figure 1B, Moving image 2).

A clinical discussion of optimal cell access and concern for chimney stent deformation if stents...