Abstract
BACKGROUND: A 72-year-old patient presented with breathlessness and presyncope due to severe stenosis within a 25-mm Perimount bioprosthetic aortic valve. The patient had hepatic cirrhosis and was not a candidate for redo surgical valve replacement. A computed tomography transcatheter aortic valve implantation (TAVI) demonstrated severe aorto-ostial left main calcific disease, with dense calcification from the annulus to the inferior border of the left main ostium, which was thought to represent a retained native leaflet, with high risk of coronary obstruction. CASE SUMMARY: Using cerebral protection, rotational atherectomy was undertaken through the aorto-ostial calcification and retained leaflet, followed by left main stem percutaneous coronary intervention. A staged TAVI with a 23-mm Sapien S3 and a chimney stent for coronary protection was successful. DISCUSSION: Although concomitant left main stem rotational atherectomy and TAVI have been described, no reports of rotablation to facilitate leaflet modification have been identified. TAKE-HOME MESSAGE: Rotational atherectomy helped to modify the retained aortic valve leaflet and safely facilitate TAVI in a nonsurgical candidate.