Coronary Access After TAVR-in-TAVR as Evaluated by Multidetector Computed Tomography.

OBJECTIVES

The aim of this study was to assess coronary accessibility after transcatheter aortic valve replacement (TAVR)-in-TAVR using multidetector computed tomography.

BACKGROUND

Expanding TAVR to patients with longer life expectancy may involve more frequent bioprosthetic valve failure and need for redo TAVR. Coronary access after TAVR-in-TAVR may be challenging, particularly as the leaflets from the initial transcatheter heart valve (THV) will form a neo-skirt following TAVR-in-TAVR.

METHODS

In 45 patients treated with different combinations of CoreValve and Evolut (CV/EV) THVs with supra-annular leaflet position and SAPIEN THVs with intra-annular leaflet position, post-TAVR-in-TAVR multidetector computed tomographic scans were analyzed to examine coronary accessibility.

RESULTS

After TAVR-in-TAVR, the coronary arteries originated below the top of the neo-skirt in 90% of CV/EV-first cases compared with 67% of SAPIEN-first cases (p = 0.009). For these coronary arteries originating below the top of the neo-skirt, the distance between the THV and the aortic wall was <3 mm in 56% and 25% of CV/EV-first and SAPIEN-first cases, respectively (p = 0.035). Coronary access may be further complicated by THV-THV stent frame strut misalignment in 53% of CV/EV-in-CV/EV cases. The risk for technically impossible coronary access was 27% and 10% in CV/EV-first and SAPIEN-first cases, respectively (p = 0.121). Absence of THV interference with coronary accessibility can be expected in 8% and 33% of CV/EV-first and SAPIEN-first cases, respectively (p = 0.005).

CONCLUSIONS

Coronary access after TAVR-in-TAVR may be challenging in a significant proportion of patients. THVs with intra-annular leaflet position or low commissural height and large open cells may be preferable in terms of coronary access after TAVR-in-TAVR.

Informations de copyright

Copyright © 2020 American College of Cardiology Foundation. Published by Elsevier Inc. All rights reserved.

Déclaration de conflit d'intérêts

Author Relationship With Industry Dr. De Backer has received institutional research grants and consulting fees from Abbott and Boston Scientific. Dr. Kim has been a proctor for and has received speaking fees from Abbott, Boston Scientific, Edwards Lifesciences, and Medtronic. Dr. Thomas Pilgrim has received institutional research grants and speaking fees from Biotronik and Boston Scientific; and is a consultant for HighLife SAS. Dr. Barbanti has received consulting fees from Edwards Lifesciences. Dr. Nombela-Franco has received consulting fees from Abbott, Boston Scientific, and Edwards Lifesciences. Dr. Kofoed has received institutional grants from AP Møller og Hustru Chastine McKinney Møllers Fond, the John and Birthe Meyer Foundation, The Research Council of Rigshopitalet, the University of Copenhagen, the Danish Heart Foundation, the Danish Agency for Science, Technology and Innovation by The Danish Council for Strategic Research, and Canon Medical Corporation. Dr. Windecker has received research and educational grants to the institution from Abbott, Amgen, Bristol Myers Squibb, Bayer, Boston Scientific, Biotronik, Cardinal Health, CSL Behring, Daiichi-Sankyo, Edwards Lifesciences, Johnson & Johnson, Medtronic, Querbet, Polares, Sanofi, Terumo, and Sinomed. Dr. Sinning has received speaking honoraria and research grants from Abbott, Abiomed, Medtronic, Boston Scientific, and Edwards Lifesciences. Dr. Webb has received institutional research grants and consulting fees from Abbott, Boston Scientific, and Edwards Lifesciences. Prof. Dr. Søndergaard has received institutional research grants and consulting fees from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, and Symetis. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.