Transcatheter aortic valve implantation (TAVI) is the treatment of choice for severe symptomatic aortic stenosis in inoperable patients, and an alternative treatment for those at high risk. The coexistence of coronary artery disease (CAD) adds morbidity and mortality to the procedure. Prior percutaneous coronary intervention (PCI) has been suggested as safe and related to a better prognosis. However, PCI in the left main coronary artery (LMCA) prior to TAVI has been poorly represented in clinical trials and scarcely reported. Herein are presented three cases of a successful sequential approach by LMCA stenting and TAVI, underlining the importance of clinical and anatomic assessment by a multidisciplinary team. Future studies will be necessary to provide more evidence for this indication. The Journal of Heart Valve Disease 2013;22: Transcatheter aortic valve implantation (TAVI) is the treatment of choice for severe symptomatic aortic stenosis in inoperable patients, and an alternative treatment for those at high risk (1). The evidence of its safety in patients with prior percutaneous coronary intervention (PCI) of the left main coronary artery (LMCA) is scarce (2,3). Moreover, LMCA disease has been poorly represented in main clinical TAVI trials. Herein are reported three cases of patients who underwent TAVI after percutaneous LMCA revascularization. Cases reports The clinical, angiographic and echocardiographic characteristics of the patients are shown in Table I. All three patients had a high surgical risk (mean EuroSCORE 34.5%) and a good functional status prior to the procedure (mean Barthel index 95), which previewed clinical benefit after the intervention. The patients were evaluated by a multidisciplinary heart team before the intervention. The distance between the annulus and ostium of the LMCA, as well as the aortic root diameter (as a mean of the shortest and longest diameters), were evaluated using computed tomographic angiography (CTA) (Table I). PCI of the LMCA was performed at a mean of six months before TAVI. The indication for LMCA PCI was an acute coronary syndrome in all subjects. Prophylactic intra- aortic balloon pumping was not used in any case. The LMCA lesions were 60%, 80% and 70%, respectively (see Table I). The first lesion was further assessed using intravascular ultrasound (IVUS), while the remaining two lesions were considered significant and treated directly. All patients underwent successful PCI of the LMCA with only one stent. Two patients received drug-eluting stents, and one patient a bare metal stent due to a history of gastrointestinal bleeding. As shown in Figure 1, ostial coverage of the LMCA was guaranteed by bulging the stent 1-2 mm out to the aorta. No periprocedural myocardial infarctions were documented. IVUS was performed in all three cases after PCI, in order to confirm good stent deployment. Stent patency was evaluated prior to TAVI. Additional coronary lesions were present in all patients (Table I), but were only treated if they involved proximal segments with an acceptable native vessel diameter (>2.0 mm). The implanted valve was Edwards-SAPIEN XT® in all cases. The access approach was transapical in two patients and transfemoral in one patient after thoracic and peripheral CTA assessment. All TAVI procedures Transcatheter Aortic Valve Implantation in Patients with Left Main Percutaneous Coronary Intervention Joaquim Cevallos 1 , Rut Andrea 1 , Carlos Falces 1 , Victoria Martín-Yuste 1 , Xavier Freixa 1 , Bàrbara Vidal 1 , Salvatore Brugaletta 1 , Manuel Castellá 2 , Mónica Masotti 1 , Manel Sabaté 1 Departments of 1 Cardiology and 2 Cardiovascular Surgery, Hospital Clínic, IDIBAPS, University of Barcelona, Barcelona, Spain Address for correspondence: Joaquim Cevallos, Cardiology Department, Thorax Institute, Hospital Clínic, C/Villarroel 170, 08036, Barcelona, Spain e-mail: jcevallo@clinic.ub.es © Copyright by ICR Publishers 2013