Elsevier

International Journal of Cardiology

Volume 317, 15 October 2020, Pages 18-24
International Journal of Cardiology

Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement with medtronic self-expanding prosthesis: Insights from correlations with computer tomography

https://doi.org/10.1016/j.ijcard.2020.05.065Get rights and content

Highlights

  • Out of 672 patients who underwent TAVR with a self-expanding prosthesis, 32 patients (4.8%) had attempted 46 CA and 26 PCI

  • Diagnostic angiography was done in 96% of cases; selective left and right coronary angiography was achieved in 50% and 28% of cases.

  • Successful PCI was performed in 96% of the cases with significant technique modification required in 64% of cases.

  • Computed tomographic angiography allowed to establish the anatomical factors associated with difficult coronary engagement.

Abstract

Objectives

We aim to describe the feasibility, challenges, success rates and techniques utilized in coronary angiography (CA) and percutaneous coronary intervention (PCI) in patients post transcatheter aortic valve replacement (TAVR).

Background

CA and PCI after TAVR are becoming increasingly encountered in clinical practice. There have been technical difficulties reported in re-accessing the coronary arteries through the self-expanding CoreValve prosthesis.

Methods

From January 2012 to November 2017, 672 patients who underwent TAVR with a self-expanding prosthesis were retrospectively reviewed and those who had a CA and/or PCI post TAVR were analysed. Clinical characteristics, angiographic and procedural details were obtained. A subgroup of patients had computed tomographic angiography (CTA) post TAVR to evaluate positions of the coronary ostia relative to the self-expanding prosthesis. Study endpoint was successful selective engagement of coronary ostia for CA and PCI.

Results

Thirty-two patients (4.8%) had attempted 46 CA and 26 PCI after TAVR with a self-expanding valve. Mean age was 85.2 years and 41% were females. Selective left and right coronary angiography using standard catheters could be achieved in 50% and 28% of cases respectively. Successful PCI was performed in 25 cases (96%); however, significant technique modification was required in 64% of cases. CTA in 9 patients confirmed the difficulty in coronary re-access was due to a combination of the sealing skirt relationship to coronary ostia and sinotubular junction as well as commissural post orientation and significant native leaflet calcification.

Conclusions

CA and PCI post TAVR with self-expanding CoreValve is technically challenging but feasible with modification of standard techniques.

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.

References (26)

  • M. Abdelghani et al.

    Coronary access After TAVR with a self-expanding bioprosthesis: insights from computed tomography

    JACC Cardiovasc. Interv.

    (2020)
  • G.H.L. Tang et al.

    Alignment of transcatheter aortic-valve neo-commissures (ALIGN TAVR): impact on final valve orientation and coronary artery overlap

    JACC Cardiovasc. Interv.

    (2020)
  • D.H. Adams et al.

    Transcatheter aortic-valve replacement with a self-expanding prosthesis

    N. Engl. J. Med.

    (2014)
  • Cited by (10)

    • 2-Year Outcomes After Transcatheter Versus Surgical Aortic Valve Replacement in Low-Risk Patients

      2022, Journal of the American College of Cardiology
      Citation 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'Angeiologie
    • Coronary Revascularization in Patients Undergoing Aortic Valve Replacement for Severe Aortic Stenosis

      2021, JACC: Cardiovascular Interventions
      Citation 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 Interventions
      Citation 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).

    View all citing articles on Scopus
    View full text