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Left Main Protection During Transcatheter Aortic Valve Replacement With a Balloon-Expandable Valve
Ingrid Hsiung1, Nikolaos Spilias2, Najdat Bazarbashi2,3
1Department of Internal Medicine, Cleveland Clinic, Cleveland, Ohio.
Left main coronary artery protection during transcatheter aortic valve replacement (TAVR) is safe and effective. Key anatomical factors predict the need for stent placement, ensuring optimal patient outcomes.
Area of Science:
- Cardiology
- Interventional Cardiology
- Cardiac Surgery
Background:
- Coronary obstruction is a rare but serious complication of transcatheter aortic valve replacement (TAVR).
- The necessity of routine left main (LM) protection, with or without stenting, during TAVR remains debated.
- This study aimed to assess TAVR outcomes with LM protection and identify anatomical predictors for stent use.
Purpose of the Study:
- To evaluate the safety and efficacy of left main coronary artery protection during TAVR.
- To identify anatomical characteristics associated with the need for left main stent placement during TAVR.
- To compare outcomes between patients who received a left main stent and those who did not.
Main Methods:
- Retrospective review of TAVR cases (native and valve-in-valve) from 2014-2019.
- Identification of patients undergoing LM protection (wire, balloon, or stent).
- Comparison of pre-TAVR CT aortic root characteristics, procedural data, and short/long-term outcomes between stented and non-stented LM protection groups.
Main Results:
- Out of 1925 TAVR patients, 41 (2.1%) received LM protection; 10 (25%) required LM stenting.
- In native TAVR, larger prosthesis size, larger annular circumference, lower sinotubular junction to prosthesis ratio, and longer left coronary cusp were linked to stenting.
- In valve-in-valve TAVR, a short valve-to-coronary distance (<4mm) was noted in 5/6 patients, with 2 requiring LM stenting. Both groups showed excellent short-term outcomes.
Conclusions:
- Left main coronary artery protection using guidewire, balloon, or stent is safe and effective in selected high-risk TAVR patients.
- Predictors for LM stent deployment include annular circumference, prosthesis size, left coronary cusp length, LM ostial height, and sinotubular junction to prosthesis ratio.
- LM protection strategies during TAVR can be tailored based on anatomical assessments to minimize coronary obstruction risk.
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