Unveiling Hidden Threats: Intravascular Ultrasound–Guided Precise Intervention for Coronary Ostium Obstruction Risk in Bicuspid Transcatheter Aortic Valve Replacement

Coronary obstruction during transcatheter aortic valve replacement (TAVR) in bicuspid anatomy remains an unpredictable and potentially fatal complication. We report three representative bicuspid TAVR cases in which static computed tomography angiography (CTA) ratios-leaflet length relative to the sinotubular junction or coronary ostium-yielded conflicting or borderline risk signals. Intravascular ultrasound (IVUS) directly visualized dynamic coronary compromise and guided timely protective PCI. Each case highlights a distinct scenario: discordant metrics, borderline anatomy, and overt high-risk morphology. The combination of CTA and real-time IVUS provided decisive risk clarification and procedural safety. This case series underscores the limitations of static anatomic assessment and demonstrates the educational value of IVUS-guided decision-making in complex bicuspid TAVR.