Development of an Algorithm to Optimize Percutaneous Coronary Intervention Through Supra-Annular Self-Expandable...

Area of Science:

• Cardiovascular Interventions
• Medical Imaging Technology
• Structural Heart Disease

Background:

• Percutaneous coronary intervention (PCI) following transcatheter heart valve (THV) implantation presents unique challenges, particularly with supra-annular self-expandable THV (SE-THV) designs.
• Coronary ostial obstruction by SE-THV commissure posts is a known complication that can impede subsequent PCI procedures.

Observation:

• Computed tomography (CT) imaging revealed SE-THV commissure posts obstructing target coronary arteries in two elderly patients.
• Virtual reality (VR) systems were employed to fuse CT images, enabling visualization of potential SE-THV deployment frames.
• A novel tool, Evo-MAP, was developed to assess the suitability of suggested deployment frames by considering SE-THV leaflet and skirt positioning.

Findings:

• Preprocedural VR and Evo-MAP assessments facilitated the selection of optimal PCI approach routes, guiding catheters, and target deployment frames for the SE-THV.
• Successful PCI was achieved in both cases despite significant misalignment of the SE-THV towards the coronary ostium.
• The integrated VR and Evo-MAP approach effectively addressed the complexities of PCI in the context of challenging SE-THV positioning.

Implications:

• This novel imaging and assessment concept offers a strategy to overcome the technical difficulties associated with PCI after SE-THV implantation.
• The described methodology has the potential to minimize the procedural complexity and improve outcomes for patients requiring PCI post-SE-THV.
• This approach may enhance the safety and feasibility of performing complex coronary interventions in patients with previously implanted SE-THVs.