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Published on: June 3, 2018
Risk Assessment of Coronary Obstruction During Transcatheter Aortic Valve Replacement: Insights From Post-BASILICA
Mitsunobu Kitamura1, Johannes Wilde1, Oliver Dumpies1
1Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
Insights
Preprocedural CT measurements can predict coronary obstruction during transcatheter aortic valve replacement (TAVR). The bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure reduced actual coronary events.
Area of Science:
- Cardiology
- Radiology
- Medical Devices
Background:
- Coronary obstruction is a risk during transcatheter aortic valve replacement (TAVR).
- Patient selection for preventative procedures requires better evaluation.
- Preprocedural computed tomography (CT) can assess risk.
Purpose of the Study:
- To evaluate the predictive accuracy of preprocedural CT geometric measurements for coronary obstruction after TAVR.
- To assess the effectiveness of the BASILICA procedure in preventing coronary events.
Main Methods:
- Analyzed pre- and postprocedural CT scans of 28 patients undergoing TAVR with BASILICA.
- Defined threatened coronary obstruction (TCO) based on postprocedural CT findings (ostial obstruction, sinus sequestration).
- Correlated preprocedural CT measurements (virtual THV-to-coronary distance, virtual THV-to-STJ distance, leaflet-STJ mismatch) with TCO incidence.
Main Results:
- Complete TCO occurred in 25.4% of leaflets post-TAVR.
- Preprocedural CT identified high-risk leaflets for TCO (53% incidence) with specific geometric criteria (VTC < 3.0 mm or VTSTJ < 1.0 mm with leaflet-STJ mismatch < 0 mm).
- The BASILICA procedure resulted in a 29% absolute risk reduction in actual coronary events (P=0.021).
Conclusions:
- A multiparametric CT approach (VTC, VTSTJ, leaflet-STJ mismatch) can improve risk assessment for post-TAVR coronary obstruction.
- BASILICA demonstrated efficacy in reducing actual coronary events, even in cases with anticipated obstruction.
Objectives:
The aim of this study was to examine the predictive value of preprocedural computed tomography (CT)-based risk stratification of coronary obstruction during transcatheter aortic valve replacement (TAVR) on the basis of geometric measurements on postprocedural CT.
Background:
Proper patient selection for additional procedures to prevent coronary obstruction during TAVR has not been adequately evaluated.
Methods:
Pre- and postprocedural computed tomographic scans of 28 patients treated using bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) and TAVR were analyzed. Using the postprocedural computed tomographic images, threatened coronary obstruction (TCO) was defined as: 1) ostial obstruction (adherence of the transcatheter heart valve [THV] to the coronary ostium with leaflet extension above the ostium); and/or 2) sinus sequestration (THV adherence to the sinotubular junction [STJ] with leaflet extension above the STJ) and was substratified into complete and incomplete types.
Results:
A total of 51 leaflets were evaluated (88% surgical tissue valves) after excluding leaflets not visible on CT (n = 5). On postprocedural CT, complete TCO was observed in 25.4% (13 of 51 leaflets). On preprocedural CT, leaflets were at high risk for complete TCO (incidence 53%) if the virtual THV-to-coronary distance (VTC) was <3.0 mm, or if the virtual THV-to-STJ distance (VTSTJ) was <1.0 mm with STJ height - leaflet length <0 mm (leaflet-STJ mismatch). Leaflets were at low risk (incidence 0%) if the VTC was ≥3 mm and VTSTJ was ≥3.0 mm or STJ height - leaflet length was ≥+2.0 mm. Of 28 leaflets treated using BASILICA, complete TCO was seen in 35.7% (n = 10), due to sinus sequestration (100%) with coexisting ostial obstruction (30%). Actual coronary events occurred in 7.1% (n = 2) because of leaflet prolapse, corresponding to an absolute risk reduction by BASILICA of 29% (P = 0.021).
Conclusions:
Risk assessment of coronary obstruction after TAVR may improve with a multiparametric approach incorporating VTC, VTSTJ, and leaflet-STJ mismatch. BASILICA appeared to reduce actual coronary events even in leaflets with anticipated coronary obstruction.
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