TAVR with double chimney stenting from the same coronary cusp in anomalous and high-risk anatomy

We report the case of an 85-year-old female with severe aortic stenosis, who was transferred to our centre for transcatheter aortic valve replacement (TAVR) after presenting to her local hospital in acute pulmonary oedema. Computed tomography (CT) demonstrated anomalous coronary arteries, with both the right coronary artery (RCA) and left coronary artery (LCA) arising from the right coronary cusp (RCC). The coronary heights were low for both the RCA and LCA and the simulated valve to coronary (VTC) distances narrow, suggesting high risk of coronary obstruction following TAVR. Further complicating factors were an effaced aortic root, and the presence of a previous mechanical mitral valve 6 mm below the level of the aortic annular plane. In this case we discuss the pre-procedural planning considerations and procedural steps, in this case double chimney stenting from the same aortic cusp, to successfully navigate this unusual and high-risk anatomy.