IVUS-Guided UNICORN Leaflet Modification During Redo TAVR to Prevent Coronary Obstruction.

BACKGROUND: Coronary obstruction is a rare but potentially fatal complication of transcatheter aortic valve replacement (TAVR), particularly during valve-in-valve and TAVR-in-TAVR procedures. Leaflet modification techniques have emerged to reduce this risk. CASE SUMMARY: A 67-year-old woman with severe degeneration of a 26-mm SAPIEN 3 transcatheter heart valve presented with acute heart failure. Computed tomography demonstrated severe prosthetic stenosis and a high risk of left coronary obstruction (virtual valve-to-coronary distance 3.4 mm). Redo TAVR was performed using intravascular ultrasound (IVUS)-guided UNICORN (Undermining Iatrogenic Coronary Obstruction with Radiofrequency Needle) leaflet modification, followed by implantation of a 23-mm RESILIA valve. IVUS enabled precise leaflet traversal and real-time assessment of the relationship between the modified leaflet, valve frame, and left main coronary artery, resulting in an excellent procedural and hemodynamic outcome. CONCLUSIONS: This is the first reported IVUS-guided UNICORN leaflet modification during TAVR-in-TAVR, highlighting its potential to improve procedural precision and safety in patients at high risk of coronary obstruction.