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Transcatheter Aortic Valve Replacement

Abstract

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2017 AHA/ACC Focused Update of the 2014 AHA/ACC Guideline for the Management of Patients With Valvular Heart Disease: A Report of the American College of Cardiology/American Heart Association Task Force on Clinical Practice Guidelines Transcatheter or Surgical Aortic-Valve Replacement in Intermediate-Risk Patients Surgical or Transcatheter Aortic-Valve Replacement in Intermediate-Risk Patients Evolving concepts in the management of antithrombotic therapy in patients undergoing transcatheter aortic valve implantation Low Transvalvular Flow Rate Predicts Mortality in Patients With Low-Gradient Aortic Stenosis Following Aortic Valve Intervention Feasibility of Coronary Access and Aortic Valve Reintervention in Low-Risk TAVR Patients Coronary Access After TAVR With a Self-Expanding Bioprosthesis: Insights From Computed Tomography Relationship Between Hospital Surgical Aortic Valve Replacement Volume and Transcatheter Aortic Valve Replacement Outcomes
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Original ResearchVolume 13, Issue 6, March 2020

JOURNAL：JACC Cardiovasc Interv. Article Link

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

T Rogers, BC Greenspun, G Weissman et al. Keywords: coronary access; coronary artery obstruction; PCI; TAVR; valve-in-valve

ABSTRACT

OBJECTIVES - 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).

 

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.

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