Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement with medtronic self-expanding prosthesis: Insights from correlations with computer tomography
Introduction
Transcatheter aortic valve replacement (TAVR) has revolutionized the treatment of severe aortic stenosis in patients across a spectrum of surgical risk [[1], [2], [3], [4], [5], [6]]. Studies have confirmed the superiority of TAVR even in patients at low risk for surgical aortic valve replacement [7,8]. As we expand the use of TAVR to lower risk patients with favourable long-term prognosis, coronary access after TAVR has become a topic of significant interest [9].
Concomitant coronary artery disease (CAD) is common in patients with severe aortic stenosis [10]. Given the progressive nature of CAD, patients treated with TAVR valves are likely to require repeat coronary angiography (CA) and percutaneous coronary intervention (PCI) in the future. However, accessing the coronary arteries in patients with TAVR valves has been associated with technical difficulties [[11], [12], [13], [14], [15], [16], [17]]. Due to its design, selective coronary engagement can be challenging in patients with self-expanding CoreValve and Evolut (Medtronic Inc., Minneapolis, MN, USA)) [9]. In one series, selective coronary engagement through a CoreValve was only feasible in 30% of cases [16]. Percutaneous coronary intervention (PCI) has also been associated with challenges with reported success rate of 90% [18]. There has also been case report of a catheter getting caught in the stent frame contributing to a patient's death [19].
Given the potential issues regarding CA and PCI through Corevalve, we aim to describe our experience of CA and PCI after CoreValve TAVR, including a subgroup of patients with post-TAVR computed tomographic angiography (CTA) to clarify the potential mechanism of difficulty in coronary re-access [4].
Section snippets
Materials and methods
This retrospective study included consecutive patients who had CA and/or PCI post TAVR with the self-expanding CoreValve or Evolut at our institution from January 2012 to November 2017. Patients who had valve-in-valve TAVR and those treated with other TAVR valves were excluded. Clinical and procedural characteristics of the included patients were obtained from the institutional database. Our study was approved by our Institutional Review Board and patient consent was waived.
Primary endpoints
Results
Of the 672 patients treated with CoreValve/Evolut in our institution between January 1, 2012 and November 30, 2017, 32 (4.8%) patients, 25 CoreValve and 7 Evolut, required a total 46 coronary procedures at a median (interquartile range) interval of 17.4 (8.2 to 30.4) months post TAVR. Baseline patient characteristics are shown in Table 1. Mean age was 85.2 years and 41% of the patients were female. Nearly half of the patients (41%) had previous PCI. ST-elevation myocardial infarction (STEMI) in
Discussion
In this retrospective study of CA and PCI through the self-expanding CoreValve/Evolut R, 3 major findings emerged. First, CA using standard catheters was challenging with a selective coronary engagement rate 50% for left and 28% for right coronaries. Despite this, diagnostic angiography could be obtained in 96% of cases and patients requiring PCI also had a 96% success rate. Second, experienced operators can usually successfully perform PCI but this requires advanced coronary equipment and
Funding
The study was supported by Medtronic, Inc (Minneapolis, MN, USA). investigator-sponsored study program.
Disclosures
Dr. Tang is a physician proctor for Medtronic and a consultant for Medtronic, Abbott Structural Heart and W. L. Gore and Associates. Dr. Sharma has no conflicts of interest relating to this manuscript. All other authors have no conflicts of interest to disclose.
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Cited by (10)
2-Year Outcomes After Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients
2022, Journal of the American College of CardiologyCitation Excerpt :In experienced centers, the success rate of coronary engagement and percutaneous coronary intervention post-TAVR with the CoreValve/Evolut platform has been shown to be >90%.38 However, it is critical that interventional cardiologists recognize that technique modification may be required to achieve selective coronary engagement through the supra-annular valve frame.39 Techniques such as commissural alignment of the prosthesis during implant may also help to facilitate coronary engagement post-TAVR for all patients undergoing TAVR.40
Challenges of coronary catheterization after TAVR
2021, Annales de Cardiologie et d'AngeiologieCoronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis
2021, JACC: Cardiovascular InterventionsCitation Excerpt :However, performing PCI after TAVR can be technically challenging, as access to the coronary ostia can be partially obstructed by the native leaflets or the prosthetic valve’s commissural posts or skirt, especially in the case of a supra-annular self-expanding prosthesis (87-89). However, more recent studies have reported high success rates for PCI post-TAVR (>95%) regardless of valve prosthesis type (90-92). Challenging cases may require modifications to PCI technique (87) and benefit from computed tomographic angiography to assist in planning PCI (92) and pre-TAVR simulation to assess the effect of the prosthesis on coronary hemodynamic status and its position relative to the coronary ostia (93).
Unplanned Percutaneous Coronary Revascularization After TAVR: A Multicenter International Registry
2021, JACC: Cardiovascular InterventionsCitation Excerpt :Recently, 2 single-center registries reported a PCI success rate in patients treated with TAVR of 96%, consistent with the findings of the present study (96.6%) (24,25). Overall, the success rate reported in previous studies was 96% to 100% when PCI was indicated for CAD (19,20,24–28) but was much lower in the presence of a coronary obstruction after valve deployment (22,23). There have been numerous case reports and small case series published since the first case report highlighting successful PCI post-TAVR with a balloon-expandable valve in 2007 (Supplemental Table 3) (29–41).
Unravelling the Fate of Coronary Artery Disease in Patients Undergoing Valve Replacement for Severe Aortic Valve Stenosis
2023, Reviews in Cardiovascular Medicine