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Impact of leaflet splitting on coronary access after redo-TAVI for degenerated supra-annular self-expanding platforms

Alessandro Beneduce1, Arif A Khokhar2,3, Jonathan Curio4

  • 1Heart Valve Center, IRCCS San Raffaele Scientific Institute, Milan, Italy.

Eurointervention : Journal of Europcr in Collaboration with the Working Group on Interventional Cardiology of the European Society of Cardiology
|June 18, 2024
PubMed

Insights

Leaflet splitting (LS) significantly improves coronary access (CA) feasibility after redo-transcatheter aortic valve implantation (TAVI) in challenging anatomies. This technique is crucial for enabling subsequent CA in patients with degenerated self-expanding valves.

Area of Science:

  • Cardiovascular interventions
  • Structural heart disease
  • Medical device technology

Background:

  • Coronary access (CA) poses a significant challenge during redo-transcatheter aortic valve implantation (TAVI), particularly with failing supra-annular self-expanding transcatheter aortic valves (TAVs).
  • Ensuring safe and feasible coronary access is critical for patient outcomes in redo-TAVI procedures.

Purpose of the Study:

  • To evaluate the effectiveness of leaflet splitting (LS) in improving subsequent coronary access (CA) after redo-TAVI.
  • To assess LS benefit in anatomies identified as high-risk for unfeasible CA.

Main Methods:

  • Utilized ex vivo, patient-specific 3D-printed models for TAVI simulations.
  • Performed index TAVI with supra-annular self-expanding valves (ACURATE neo2 or Evolut PRO) at varying commissural misalignment (CMA).
  • Conducted redo-TAVI with a balloon-expandable valve (SAPIEN 3 Ultra) at different depths, assessing selective CA before and after LS in a pulsatile flow simulator.

Main Results:

  • Overall CA feasibility significantly increased from 18.7% to 60.9% after LS (p<0.001).
  • LS enabled CA up to 45° CMA for ACURATE neo2 and 30° CMA for Evolut PRO TAV-1.
  • The combination of LS and a low SAPIEN 3 Ultra implant depth yielded the highest CA feasibility in redo-TAVI scenarios.

Conclusions:

  • Leaflet splitting (LS) substantially enhances coronary access feasibility in high-risk anatomies undergoing redo-TAVI for degenerated supra-annular self-expanding platforms.
  • Individualized treatment decisions for redo-TAVI should incorporate the anticipated benefits of LS on coronary access for specific patient anatomies.
Abstract

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