Left main percutaneous coronary intervention after Medtronic CoreValve TAVR: Navigating coronary access challenges

Transcatheter aortic valve replacement (TAVR) is the standard of care for high-risk patients with severe aortic stenosis. However, coronary access post-TAVR remains a challenge, particularly in patients with the Medtronic CoreValve, due to its supra-annular design and extended frame, which can obstruct engagement of the coronary ostia. Managing acute coronary syndromes in this subset of patients often requires advanced procedural techniques. We present the case of a 78-year-old female with a history of TAVR with Medtronic CoreValve who presented with non-ST-segment elevation myocardial infarction (NSTEMI) and underwent successful but challenging percutaneous coronary intervention (PCI) of left main coronary artery due to the difficult coronary engagement and wiring secondary to the presence of CoreValve. This case highlights the procedural difficulties of PCI in patients with CoreValve TAVR, emphasizing the importance of catheter selection and strategic planning for coronary interventions in these patients. As TAVR usage continues to rise, clinicians must be aware of post-TAVR PCI challenges and consider advanced guide catheter techniques and multidisciplinary collaboration to optimize revascularization outcomes in this high-risk population.