Coronary Access After TAVR-in-TAVR as Evaluated by Multidetector Computed Tomography

Area of Science:

• Cardiology
• Interventional Cardiology
• Cardiac Imaging

Background:

• Expanding transcatheter aortic valve replacement (TAVR) to younger patients necessitates addressing bioprosthetic valve failure and repeat procedures.
• Coronary access after TAVR-in-TAVR is a growing concern due to potential obstruction from the initial transcatheter heart valve (THV) leaflets forming a neo-skirt.

Purpose of the Study:

• To evaluate coronary artery accessibility following TAVR-in-TAVR procedures.
• To compare coronary access outcomes between different THV designs and leaflet positions.

Main Methods:

• Analysis of multidetector computed tomographic scans in 45 patients who underwent TAVR-in-TAVR.
• Categorization of patients based on initial THV type: CoreValve/Evolut (CV/EV) with supra-annular leaflets and SAPIEN with intra-annular leaflets.

Main Results:

• Coronary arteries originated below the neo-skirt in 90% of CV/EV-first cases versus 67% of SAPIEN-first cases (p=0.009).
• The distance between the THV and aortic wall was <3 mm in 56% of CV/EV-first cases compared to 25% of SAPIEN-first cases (p=0.035).
• THV-THV stent frame misalignment complicated access in 53% of CV/EV-in-CV/EV cases, with impossible access rates of 27% (CV/EV-first) and 10% (SAPIEN-first).

Conclusions:

• Coronary access after TAVR-in-TAVR presents significant challenges.
• THVs with intra-annular leaflet position, low commissural height, and large open cells may facilitate better coronary access in TAVR-in-TAVR scenarios.