Author + information
- Received August 5, 2019
- Revision received December 23, 2019
- Accepted January 2, 2020
- Published online March 16, 2020.
- Toby Rogers, MD, PhDa,b,
- Benjamin C. Greenspun, BSa,
- Gaby Weissman, MDc,
- Rebecca Torguson, MPHa,
- Paige Craig, MPHa,
- Christian Shults, MDd,
- Paul Gordon, MDe,
- Afshin Ehsan, MDf,
- Sean R. Wilson, MDg,
- John Goncalves, MDh,
- Robert Levitt, MDi,
- Chiwon Hahn, MDj,
- Puja Parikh, MDk,
- Thomas Bilfinger, MD, ScDl,
- David Butzel, MDm,
- Scott Buchanan, MDm,
- Nicholas Hanna, MDn,
- Robert Garrett, MDo,
- Maurice Buchbinder, MDp,
- Federico Asch, MDq,
- Hector M. Garcia-Garcia, MDq,
- Petros Okubagzi, MDa,
- Itsik Ben-Dor, MDa,
- Lowell F. Satler, MDa and
- Ron Waksman, MDa,∗ ()
- aSection of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC
- bCardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland
- cDepartment of Cardiology, MedStar Washington Hospital Center, Washington, DC
- dDivision of Cardiothoracic Surgery, MedStar Washington Hospital Center, Washington, DC
- eDivision of Cardiology, The Miriam Hospital, Providence, Rhode Island
- fDivision of Cardiothoracic Surgery, Lifespan Cardiovascular Institute, Providence, Rhode Island
- gDepartment of Medicine, The Valley Hospital, Ridgewood, New Jersey
- hCardiac Surgery Program, The Valley Hospital, Ridgewood, New Jersey
- iDepartment of Cardiology, Henrico Doctors’ Hospital, Richmond, Virginia
- jDepartment of Cardiothoracic Surgery, Henrico Doctors’ Hospital, Richmond, Virginia
- kDepartment of Medicine, Stony Brook Hospital, Stony Brook, New York
- lDepartment of Surgery, Stony Brook Hospital, Stony Brook, New York
- mCardiovascular Service Line, Maine Medical Center, Portland, Maine
- nSt. John Heart Institute Cardiovascular Consultants, St. John Health System, Tulsa, Oklahoma
- oSt. John Clinic Cardiovascular Surgery, St. John Heart Institute Cardiovascular Consultants, St. John Health System, Tulsa, Oklahoma
- pFoundation for Cardiovascular Medicine, Stanford University, Stanford, California
- qMedStar Health Research Institute, MedStar Washington Hospital Center, Washington, DC
- ↵∗Address for correspondence:
Dr. Ron Waksman, MedStar Washington Hospital Center, 110 Irving Street, NW, Suite 4B-1, Washington, DC 20010.
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.
- coronary access
- coronary artery obstruction
- percutaneous coronary intervention
- transcatheter aortic valve replacement
The LRT trial was funded by MedStar Health Research Institute. Dr. Rogers is a consultant and proctor for Medtronic; and is a proctor for Edwards Lifesciences. Dr. Weissman is director of an academic cardiovascular imaging core laboratory with institutional contracts with Boston Scientific, Ancora Heart, LivaNova, and HDL Therapeutics. Dr. Goncalves is a proctor for Medtronic. Dr. Hanna is a speaker for Edwards Lifesciences. Dr. Asch is director of an academic cardiovascular imaging core laboratory with institutional contracts with Edwards Lifesciences, Medtronic, Boston Scientific, Biotronik, and Abbott. Dr. Waksman is an advisory board member for Amgen, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips, and Pi-Cardia; is a consultant for Amgen, Biotronik, Boston Scientific, Cardioset, Cardiovascular Systems Inc., Medtronic, Philips, and Pi-Cardia; has received grant support from AstraZeneca, Biotronik, Boston Scientific, and Chiesi; is a member of the Speakers Bureau of AstraZeneca and Chiesi; and is an investor in MedAlliance. All other authors have reported that they have no relationships relevant to the contents of this paper to disclose.
- Received August 5, 2019.
- Revision received December 23, 2019.
- Accepted January 2, 2020.
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