Can we perform rotational atherectomy in patients with severe aortic stenosis? Substudy from the OCEAN TAVI Registry

The aim of this study was to report the safety of coronary rotational atherectomy (RA) in patients with severe aortic stenosis (AS). RA in the clinical setting seems challenging because coronary slow flow leads to hemodynamic instability.

Between October 2013 and May 2016, 1401 patients in the Optimized transCathEter vAlvular iNtervention (OCEAN) registry in Japan underwent transcatheter aortic valve implantation (TAVI). The primary study endpoint was procedural success, defined as residual stenosis <20% with final Thrombolysis in Myocardial Infarction flow 3.

Twenty-five patients who underwent RA for heavily calcified lesions were included in the study. Low left ventricular ejection fraction (<35%) was present in 3 (12%) patients. The left main stem was involved in 7 (28%) patients. All patients were treated under intravascular image guidance. Intra-aortic balloon pumping was used in 4 (16%) patients. Planned balloon aortic valvuloplasty (BAV) was performed during the same session in 4 (16%) patients. Transvenous catecholamine was used in 10 (40%) patients. The majority of patients underwent drug-eluting stent implantation following RA (n=23, 92%). Procedural success was achieved in all patients. Subsequent device success was achieved in 24 (96%) patients, with no 30-day mortality following TAVI.

RA in patients with severe AS seems extremely challenging; however, this procedure appears to be safe if mechanical and drug supports are appropriately utilized and the procedure is performed under intravascular image guidance.