Unprotected TAVI with Critically Low LMCA Height: The Importance of Individualized Anatomical Assessment

A 66-year-old woman with severe symptomatic aortic stenosis (STS-PROM 5.15%; EuroSCORE II 3.66%), right carotid occlusion, 50% left carotid stenosis, and a preference for TAVI underwent multidisciplinary assessment. Computed tomography demonstrated a 6 mm left main coronary artery (LMCA) ostial height, hypoplastic right coronary artery, 31 mm left coronary sinus, and no bulky calcification facing the LMCA. Following Heart Team assessment of obstruction risk and the potential complications of prophylactic stenting, transfemoral TAVI was performed without coronary protection using a 29 mm recapturable self-expanding valve, with emergency revascularization, hemodynamic support, and surgical backup available. Preserved left coronary perfusion after 18 mm balloon predilatation provided reassurance but could not exclude obstruction during valve deployment. Recovery was uneventful, with no reported adverse cardiovascular events during approximately 18 months of follow-up. Favorable sinus anatomy may inform procedural planning but cannot independently establish protection against coronary obstruction. This single case illustrates individualized anatomical assessment and Heart Team decision-making, not the general safety of omitting coronary protection in similarly high-risk patients.