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Overcoming the transcatheter aortic valve replacement Achilles heel: coronary re-access

Arash Arshi1, Steven J Yakubov1, Kevin L Stiver1

  • 1OhioHealth Riverside Methodist Hospital, Columbus, Ohio, USA.

Annals of Cardiothoracic Surgery
|December 14, 2020
PubMed

Insights

Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for severe aortic stenosis. Coronary angiography after TAVR is increasingly important for managing coronary artery disease, with techniques to ensure safe re-access.

Area of Science:

  • Cardiology
  • Interventional Cardiology
  • Cardiovascular Surgery

Background:

  • Severe aortic stenosis (AS) is often treated with transcatheter aortic valve replacement (TAVR) or surgical aortic valve replacement (SAVR).
  • Coronary artery disease (CAD) frequently coexists with severe AS.
  • As TAVR expands to lower-risk populations, patients will increasingly require future coronary angiography after TAVR.

Purpose of the Study:

  • To review techniques for safe coronary artery re-access after TAVR.
  • To discuss strategies for preventing and managing coronary artery obstruction during TAVR, especially in valve-in-valve procedures.
  • To outline catheter selection and engagement strategies for specific transcatheter aortic valve bioprostheses.

Main Methods:

  • Review of existing literature and clinical experience regarding coronary angiography post-TAVR.
  • Analysis of factors influencing successful coronary artery re-access, including prosthesis-ostial alignment.
  • Discussion of techniques to mitigate coronary obstruction risk during TAVR procedures.

Main Results:

  • Coronary artery re-access after TAVR is feasible in most cases, though challenging.
  • Commissural alignment of the TAV prosthesis is critical for successful coronary ostial engagement.
  • Coronary artery obstruction is a significant risk, particularly in valve-in-valve TAVR.

Conclusions:

  • Coronary angiography after TAVR is an essential component of comprehensive cardiovascular care.
  • Careful planning and specific techniques are necessary to ensure safe coronary artery re-access and prevent obstruction.
  • Understanding prosthesis-coronary anatomy is key to successful outcomes in patients with prior TAVR undergoing further interventions.

Keywords:
Aortic stenosis (AS)coronary artery disease (CAD)transcatheter aortic valve replacement (TAVR)

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