Feasibility of Coronary Access and Aortic Valve Reintervention in Low-Risk TAVR Patients.

Aged Aortic Valve / diagnostic imaging Aortic Valve Stenosis / diagnostic imaging Bioprosthesis Cardiac Catheterization / adverse effects Computed Tomography Angiography Coronary Angiography Coronary Stenosis / diagnostic imaging Coronary Vessels / diagnostic imaging Feasibility Studies Female Heart Valve Prosthesis Humans Male Multidetector Computed Tomography Predictive Value of Tests Prospective Studies Prosthesis Design Retreatment Risk Factors Severity of Illness Index Time Factors Transcatheter Aortic Valve Replacement / adverse effects Treatment Outcome United States

coronary access coronary artery obstruction percutaneous coronary intervention transcatheter aortic valve replacement valve-in-valve

Journal

JACC. Cardiovascular interventions

ISSN: 1876-7605

Titre abrégé: JACC Cardiovasc Interv

Pays: United States

ID NLM: 101467004

Informations de publication

Date de publication:
23 03 2020

Historique:

received: 05 08 2019

revised: 23 12 2019

accepted: 02 01 2020

entrez: 21 3 2020

pubmed: 21 3 2020

medline: 21 10 2020

Statut: ppublish

Résumé

The aim of this study was to evaluate the feasibility of coronary access and aortic valve reintervention in low-risk patients undergoing transcatheter aortic valve replacement (TAVR) with a balloon-expandable transcatheter heart valve (THV). Younger, low-risk TAVR patients are more likely than older, higher risk patients to require coronary angiography, percutaneous coronary intervention, or aortic valve reintervention, but their THVs may impede coronary access and cause coronary obstruction during TAVR-in-TAVR. The LRT (Low Risk TAVR) trial (NCT02628899) enrolled 200 subjects with symptomatic severe aortic stenosis to undergo TAVR using commercially available THVs. Subjects who received balloon-expandable THVs and who had 30-day cardiac computed tomographic scans were included in this study. In a subgroup, the feasibility of intentional THV crimping on the delivery catheter to pre-determine commissural alignment was tested. In the LRT trial, 168 subjects received balloon-expandable THVs and had 30-day cardiac computed tomographic scans, of which 137 were of adequate image quality for analysis. The most challenging anatomy for coronary access (THV frame above and commissural suture post in front of a coronary ostium) was observed in 9% to 13% of subjects. Intentional THV crimping did not appear to meaningfully affect commissural alignment. The THV frame extended above the sinotubular junction in 21% of subjects, and in 13%, the distance between the THV and the sinotubular junction was <2 mm, signifying that TAVR-in-TAVR may not be feasible without causing coronary obstruction. TAVR may present challenges to future coronary access and aortic valve reintervention in a substantial number of low-risk patients.

Sections du résumé

OBJECTIVES

BACKGROUND

Younger, low-risk TAVR patients are more likely than older, higher risk patients to require coronary angiography, percutaneous coronary intervention, or aortic valve reintervention, but their THVs may impede coronary access and cause coronary obstruction during TAVR-in-TAVR.

METHODS

The LRT (Low Risk TAVR) trial (NCT02628899) enrolled 200 subjects with symptomatic severe aortic stenosis to undergo TAVR using commercially available THVs. Subjects who received balloon-expandable THVs and who had 30-day cardiac computed tomographic scans were included in this study. In a subgroup, the feasibility of intentional THV crimping on the delivery catheter to pre-determine commissural alignment was tested.

RESULTS

In the LRT trial, 168 subjects received balloon-expandable THVs and had 30-day cardiac computed tomographic scans, of which 137 were of adequate image quality for analysis. The most challenging anatomy for coronary access (THV frame above and commissural suture post in front of a coronary ostium) was observed in 9% to 13% of subjects. Intentional THV crimping did not appear to meaningfully affect commissural alignment. The THV frame extended above the sinotubular junction in 21% of subjects, and in 13%, the distance between the THV and the sinotubular junction was <2 mm, signifying that TAVR-in-TAVR may not be feasible without causing coronary obstruction.

CONCLUSIONS

TAVR may present challenges to future coronary access and aortic valve reintervention in a substantial number of low-risk patients.

Identifiants

DOI: 10.1016/j.jcin.2020.01.202 PMID: 32192693

pubmed: 32192693

pii: S1936-8798(20)30268-5

doi: 10.1016/j.jcin.2020.01.202

pii:

doi:

Types de publication

Journal Article Multicenter Study Research Support, Non-U.S. Gov't

Langues

eng

Sous-ensembles de citation

Pagination

726-735

Commentaires et corrections

Type : CommentIn