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

De Backer, Ole; Landes, Uri; Fuchs, Andreas; Yoon, Sung-Han; Mathiassen, Ole Norling; Sedaghat, Alexander; Kim, Won-Keun; Pilgrim, Thomas; Buzzatti, Nicola; Ruile, Philipp; El Sabbagh, Abdallah; Barbanti, Marco; Fiorina, Claudia; Nombela-Franco, Luis; Steinvil, Arie; Finkelstein, Ariel; Montorfano, Matteo; Maurovich-Horvat, Pal; Kofoed, Klaus Fuglsang; Blanke, Philipp; ... (2020). Coronary Access After TAVR-in-TAVR as Evaluated by Multidetector Computed Tomography. JACC. Cardiovascular Interventions, 13(21), pp. 2528-2538. Elsevier 10.1016/j.jcin.2020.06.016

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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.

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