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Coronary Access After TAVR

Tomoki Ochiai1, Tarun Chakravarty2, Sung-Han Yoon2

  • 1Smidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California; Department of Cardiology, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan. Electronic address: https://twitter.com/TomokiOchiai.

JACC. Cardiovascular Interventions
|March 21, 2020
PubMed

Insights

Unfavorable coronary access after transcatheter aortic valve replacement (TAVR) is common, especially with certain valve types. Features identified by computed tomography (CT) predict challenges in future coronary engagement.

Area of Science:

  • Cardiovascular Medicine
  • Interventional Cardiology
  • Medical Imaging

Background:

  • Coronary access after transcatheter aortic valve replacement (TAVR) is crucial for managing potential complications.
  • Limited real-world data exists on the incidence and predictors of unfavorable coronary access post-TAVR.
  • Post-implantation computed tomography (CT) is a valuable tool for assessing anatomical relationships after TAVR.

Purpose of the Study:

  • To evaluate the frequency of unfavorable coronary access following TAVR using post-implantation CT.
  • To compare the incidence of unfavorable coronary access between different TAVR valve designs (Evolut R/PRO vs. SAPIEN 3).
  • To determine the impact of CT-identified unfavorable coronary access on subsequent coronary engagement success.

Main Methods:

  • Retrospective analysis of post-TAVR CT scans from patients who received Evolut R/PRO (n=66) or SAPIEN 3 (n=345) valves.
  • Assessment of the distance between the transcatheter heart valve (THV) inflow and coronary ostia, and overlap with THV commissures.
  • Definition of unfavorable coronary access based on the position of the coronary ostium relative to the THV skirt and commissural posts.

Main Results:

  • Unfavorable coronary access features were observed in 34.8% (left) and 25.8% (right) of the Evolut R/PRO group, versus 15.7% (left) and 8.1% (right) in the SAPIEN 3 group.
  • Selective coronary engagement success rates were significantly lower in patients with unfavorable coronary access (0.0% for Evolut R/PRO, 33.3% for SAPIEN 3) compared to favorable access (77.8% for Evolut R/PRO, 91.4% for SAPIEN 3).
  • These differences were statistically significant (p=0.003) for both valve types.

Conclusions:

  • Coronary access can be challenging in a substantial number of patients post-TAVR.
  • THV designs with lower skirts, commissure heights, and larger open cells may improve future coronary access.
  • CT assessment of post-TAVR anatomy is essential for predicting and potentially mitigating coronary access difficulties.
Abstract

Keywords:
aortic valve stenosiscoronary angiographycoronary artery diseasepercutaneous coronary interventiontranscatheter aortic valve replacement

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