TAVR in anomalous origin of the right coronary artery with interarterial course and acute takeoff angle

José M. Alanís-Naranjo, Imaging Unit, Hospital Clínico San Carlos, Madrid, Spain
Oscar M. Granados-Casas, Department of Interventional Cardiology, Hospital Regional 1 de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico City, Mexico
Cielmar Galeana-Abarca, Department of Cardiology, Hospital Regional 1 de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico City, Mexico
Julio C. Mayen-Casas, Department of Interventional Cardiology, Hospital Regional 1 de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico City, Mexico
Kevin D. Aragón-Ontiveros, Department of Cardiology, Hospital Regional 1 de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico City, Mexico
Arturo E. Gudiño-Resendez, Department of Cardiology, Hospital Regional 1 de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico City, Mexico
Alejandro Alcocer-Chauvet, Department of Interventional Cardiology, Hospital Regional 1 de Octubre, Instituto de Seguridad y Servicios Sociales de los Trabajadores del Estado, Mexico City, Mexico

Anomalous aortic origin of the coronary arteries (AAOCA) is an infrequent finding that may increase the risk of coronary obstruction during transcatheter aortic valve replacement (TAVR). We report the case of an 80-year-old woman with severe aortic stenosis and anomalous origin of the right coronary artery (RCA) from the left coronary sinus, with an interarterial course and an acute takeoff angle. Preprocedural coronary angiography showed ostioproximal occlusion. Intravascular ultrasound demonstrated approximately 80% extrinsic compression, and coronary physiologic assessment confirmed hemodynamically significant ischemia. Given the high risk of myocardial ischemia during TAVR, the RCA was treated with drug-eluting stents before valve implantation. Subsequently, transfemoral TAVR with a self-expandable valve was performed successfully, with preserved coronary patency and no complications. At 4-year follow-up, the patient remained asymptomatic, with a normally functioning prosthetic valve and no hospital readmissions. This case underscores the importance of detailed preprocedural imaging, coronary physiology assessment, and individualized planning to minimize the risk of coronary obstruction in patients with high-risk AAOCA undergoing TAVR.

Keywords: Transcatheter aortic valve replacement. Anomalous aortic origin of the coronary arteries. Right coronary artery anomaly. Coronary computed tomography angiography. Interarterial course. Acute takeoff angle.