Author + information
- Received December 5, 2019
- Revision received January 13, 2020
- Accepted January 13, 2020
- Published online March 16, 2020.
- Tomoki Ochiai, MDa,b@TomokiOchiai,
- Tarun Chakravarty, MDa,
- Sung-Han Yoon, MDa,
- Danon Kaewkes, MDa,
- Nir Flint, MDa,c,
- Vivek Patel, MSa,
- Sahar Mahani, MDa,
- Ripandeep Tiwana, MDa,
- Navjot Sekhon, MDa,
- Mamoo Nakamura, MDa,
- Wen Cheng, MDa and
- Raj Makkar, MDa,∗ ()
- aSmidt Heart Institute, Cedars-Sinai Medical Center, Los Angeles, California
- bDepartment of Cardiology, Shonan Kamakura General Hospital, Kamakura, Kanagawa, Japan
- cTel Aviv Sourasky Medical Center affiliated to the Sackler Faculty of Medicine, Tel Aviv University, Tel Aviv, Israel
- ↵∗Address for correspondence:
Dr. Raj Makkar, Smidt Heart Institute, Cedars-Sinai Medical Center, 127 South San Vicente Boulevard, Advanced Health Sciences Pavilion, Third Floor, Suite A3100, Los Angeles, California 90048.
Objectives The aim of this study was to assess the incidence of unfavorable coronary access after transcatheter aortic valve replacement (TAVR) using post-implantation computed tomography (CT).
Background Real-world data regarding coronary access after TAVR assessed using post-implantation CT are scarce.
Methods Post-TAVR CT of 66 patients treated with Evolut R or Evolut PRO valves and 345 patients treated with SAPIEN 3 valves were analyzed. The distance from inflow of the transcatheter heart valve (THV) to the coronary ostia and the overlap between THV commissures and the coronary ostia were assessed. Coronary access was defined as unfavorable if the coronary ostium was below the skirt or in front of the THV commissural posts above the skirt in each coronary artery.
Results CT-identified features of unfavorable coronary access were observed in 34.8% (n = 23) for the left coronary artery and 25.8% (n = 17) for the right coronary artery in the Evolut R/Evolut PRO group, while those percentages were 15.7% (n = 54) for the left coronary artery and 8.1% (n = 28) for the right coronary artery in the SAPIEN 3 group. In the Evolut R/Evolut PRO group, 16 coronary engagements were performed after TAVR, while 64 coronary engagements were performed in the SAPIEN 3 group after TAVR. In an engagement-level analysis, the success rates of selective coronary engagement were significantly lower in patients with CT-identified features of unfavorable coronary access compared with those with favorable coronary access in both the Evolut R/Evolut PRO (0.0% vs. 77.8%; p = 0.003) and SAPIEN 3 (33.3% vs. 91.4%; p = 0.003) groups.
Conclusions Coronary access may be challenging in a significant proportion of patients after TAVR. THVs with low skirt or commissure height and large open cells that are designed to achieve commissure-to-commissure alignment with the native aortic valve may facilitate future coronary access. (Assessment of Transcatheter and Surgical Aortic Bioprosthetic Valve Thrombosis and Its Treatment With Anticoagulation [RESOLVE]; NCT02318342)
- aortic valve stenosis
- coronary angiography
- coronary artery disease
- percutaneous coronary intervention
- transcatheter aortic valve replacement
This work was supported by the Smidt Heart Institute, Cedars-Sinai Medical Center. Dr. Chakravarty is a consultant, proctor, and speaker for Edwards Lifesciences and Medtronic; he is a consultant for Abbott Lifesciences; and he is a consultant and speaker for Boston Scientific. Dr. Makkar has received grant support from Edwards Lifesciences; has served as a consultant for Abbott Vascular, Cordis, and Medtronic; and owns equity in Entourage Medical. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received December 5, 2019.
- Revision received January 13, 2020.
- Accepted January 13, 2020.
- 2020 American College of Cardiology Foundation
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