Transcatheter Electrosurgery for Coronary Access After TAVI-in-TAVI

BACKGROUND: Transcatheter aortic valve implantation (TAVI) is increasingly performed, with TAVI-in-TAVI reinterventions becoming more frequent. Coronary access after TAVI-in-TAVI can be severely limited by neoskirt formation. CASE SUMMARY: A 74-year-old man with extensive comorbidities and prior TAVI-in-TAVI (Evolut and Sapien valves) presented with chest pain and troponin elevation. Angiography showed severe left main artery and left anterior descending artery stenoses, but selective coronary engagement was impossible given complete neoskirt obstruction. Using transcatheter electrosurgery, a Steelcore guidewire insulated in a microcatheter was energized to perforate the neoskirt. Percutaneous coronary intervention with drug-eluting stents was successfully completed, with an excellent final result. DISCUSSION: To our knowledge, this is the first report of electrosurgical neoskirt perforation to enable coronary revascularization after TAVI-in-TAVI. TAKE-HOME MESSAGES: Electrosurgery can safely perforate a neoskirt, restoring coronary access. This novel strategy may become essential as TAVI-in-TAVI procedures increase.