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Published on: June 3, 2018
Coronary Protection to Prevent Coronary Obstruction During TAVR: A Multicenter International Registry
Tullio Palmerini1, Tarun Chakravarty2, Francesco Saia1
1Polo Cardio-Toraco Vascolare, Policlinico S. Orsola, Bologna, Italy.
Insights
Preventive stenting during transcatheter aortic valve replacement (TAVR) improves survival and reduces cardiac death. Coronary protection with wires alone carries a significant risk of delayed coronary occlusion after TAVR.
Area of Science:
- Cardiology
- Interventional Cardiology
- Medical Devices
Background:
- Coronary obstruction is a critical complication after transcatheter aortic valve replacement (TAVR).
- This complication leads to high procedural and short-term mortality rates.
Purpose of the Study:
- To evaluate the safety and effectiveness of preventive coronary stenting in high-risk TAVR patients.
- To assess outcomes of coronary protection strategies including wiring and stenting across coronary ostia.
Main Methods:
- Retrospective analysis of a multicenter international registry (April 2011 - February 2019).
- Compared outcomes between patients receiving preventive coronary wiring with stenting versus wiring alone.
- Follow-up at 3 years.
Main Results:
- Patients receiving stents had lower 3-year cardiac death rates (7.8% vs. 15.7%).
- Stent thrombosis occurred in 0.9% of stented patients, primarily in valve-in-valve procedures.
- Delayed coronary occlusion (DCO) occurred in 4.3% of patients with wire protection only.
Conclusions:
- Preventive coronary stenting in high-risk TAVR patients is associated with favorable mid-term survival.
- Coronary protection using only wires poses a substantial risk of DCO.
- Stent implantation demonstrates good safety with low thrombosis rates.
Objectives:
The aim of this study was to investigate the safety and efficacy of coronary protection by preventive coronary wiring and stenting across the coronary ostia in patients at high risk for coronary obstruction after transcatheter aortic valve replacement (TAVR).
Background:
Coronary obstruction following TAVR is a life-threatening complication with high procedural and short-term mortality.
Methods:
Data were collected retrospectively from a multicenter international registry between April 2011 and February 2019.
Results:
Among 236 patients undergoing coronary protection with preventive coronary wiring, 143 had eventually stents implanted across the coronary ostia after valve deployment. At 3-year follow-up, rates of cardiac death were 7.8% in patients receiving stents and 15.7% in those not receiving stents (adjusted hazard ratio: 0.42; 95% confidence interval: 0.14 to 1.28; p = 0.13). There were 2 definite stent thromboses (0.9%) in patients receiving stents, both occurring after TAVR in "valve-in-valve" procedures. In patients not receiving stents, there were 4 delayed coronary occlusions (DCOs) (4.3%), occurring from 5 min to 6 h after wire removal. Three cases occurred in valve-in-valve procedures and 1 in a native aortic valve procedure. Distance between the virtual transcatheter valve and the protected coronary ostia <4 mm was present in 75.0% of patients with DCO compared with 30.4% of patients without DCO (p = 0.19).
Conclusions:
In patients undergoing TAVR at high risk for coronary obstruction, preventive stent implantation across the coronary ostia is associated with good mid-term survival rates and low rates of stent thrombosis. Patients undergoing coronary protection with wire only have a considerable risk for DCO.
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