Predicting Coronary Occlusion Risk during Redo-TAVR at First TAVR: Asymmetric Calcification Causes Failure

Predicting coronary artery occlusion due to sinus sequestration (SS) during a second transcatheter aortic valve (TAV) procedure using pre-procedural computed tomography (CT) after the first TAV replacement (TAVR) is underreported. This study aimed to investigate the accuracy of SS risk prediction using pre-procedural CT by comparing it to the actual SS risk observed on post-procedural CT during TAV-in-TAV.

We retrospectively evaluated 139 consecutive patients who underwent TAVR with a balloon-expandable valve. The predicted valve-to-sinotubular junction (VTSTJ) length and calcium volume of each coronary cusp were measured on pre-procedural CT. The observed VTSTJ length was assessed on post-procedural CT. High SS risk was defined as VTSTJ < 2.0 mm in either the right or left coronary cusp. Pre-procedural CT classified 78 patients into the high predicted SS (PSS) risk group; 77 (98.7%) showed a high observed SS (OSS) risk on post-procedural CT. Among the 61 patients classified as having low PSS risk, 44 (72.1%) were found to have high OSS risk post-TAVR. In this subgroup, patients with high OSS risk had a significantly higher proportion of non-coronary cusp calcium volume (NCC-CV) compared to those with low OSS risk (median 48.7% [interquartile range (IQR): 42.1-55.2] vs. 39.2% [IQR: 33.7-45.4]; p = 0.004). Multivariable logistic regression revealed NCC-CV ≥ 41.6% as an independent predictor of high OSS risk during TAV-in-TAV (odds ratio: 12.59 [95% confidence interval: 4.20-44.14], p < 0.001).

Asymmetric NCC calcification was associated with discrepancies in SS predictions on pre-procedural CT.