Risk of Coronary Obstruction and Feasibility of Coronary Access After Repeat Transcatheter Aortic Valve Replacement With the Self-Expanding Evolut Valve

Abstract

Background: The supra-annular leaflet position and tall stent frame of the self-expanding Evolut PRO or Evolut PRO+ transcatheter heart valves (THVs) may cause coronary occlusion during transcatheter aortic valve replacement (TAVR)-in-TAVR and present challenges for future coronary access. We sought to evaluate the risk of TAVR-in-TAVR with Evolut PRO or Evolut PRO+ THVs and the feasibility of future coronary access. Methods: The CoreValve Evolut PRO Prospective Registry (EPROMPT; NCT03423459) prospectively enrolled patients with symptomatic severe aortic stenosis to undergo TAVR using a commercially available latest generation self-expanding THV at 2 centers in the United States. Computed tomography was performed 30 days after TAVR, which we used to simulate TAVR-in-TAVR with a second Evolut PRO or Evolut PRO+ THV and evaluate for risk of coronary obstruction and feasibility of future coronary access. Results: Eighty-one patients enrolled with interpretable computed tomography are reported herein. Computed tomography simulation predicted sinus of Valsalva sequestration and resultant coronary obstruction during future TAVR-in-TAVR in up to 23% of patients. Computed tomography simulation predicted that the position of the pinned THV leaflets would hinder future coronary access in up to 78% of patients after TAVR-in-TAVR. Conclusions: Further THV design improvements and leaflet modification strategies are needed to mitigate the risk of coronary obstruction during TAVR-in-TAVR with self-expanding THVs and to facilitate future coronary access. Registration: URL: https://www.clinicaltrials.gov . Unique identifier: NCT03423459.

Coronary access following ACURATE neo implantation for transcatheter aortic valve-in-valve implantation: Ex vivo analysis in patient-specific anatomies

“…Assessing the feasibility of coronary access and PCI is increasingly relevant as TAVI expands toward younger and lower-risk patients who have an increased life-time risk for repeat invasive angiography due to progression of CAD ( 9 – 12 ). Studies using pre or post-procedural CT to virtually assess coronary access have suggested that challenging or un-feasible cannulation may occur following 9–35% TAVR ( 16 – 18 ), 27–78% of TAVI-in-TAVI ( 19 , 20 , 25 ) and 58% of ViV-TAVI ( 22 ) procedures. However, data from real studies of post TAVI cannulation are more re-assuring with success rates for diagnostic cannulation and PCI success ranging between 90–100 and 92–97%, respectively, even in the acute setting ( 11 – 14 , 26 – 28 ).…”

Coronary Artery Disease in Patients Undergoing Transvalvular Aortic Valve Implantation

“…With these valve-in-valve procedures, coronary obstruction risk and access difficulty will increase. [ 88 , 89 ] Hopefully, future studies will shed light on an appropriate strategy for younger patients who have to undergo multiple such procedures.…”

Impact of blood pressure on coronary perfusion and valvular hemodynamics after aortic valve replacement

“…Clinical, in vitro, and in silico studies have shown that the implantation of a bioprosthetic valve alters the sinus flow dynamics and may compromise or obstruct coronary access, leading to potential impairment of coronary perfusion 11–16 …”

“…Clinical, in vitro, and in silico studies have shown that the implantation of a bioprosthetic valve alters the sinus flow dynamics and may compromise or obstruct coronary access, leading to potential impairment of coronary perfusion. [11][12][13][14][15][16] The aim of this study is to evaluate the impact of various BP conditions on the coronary perfusion and hemodynamic performance after AVR. These highly controlled mechanistic in vitro studies can yield evidence supporting the potential need for revised (potentially raised) optimal BP targets in patients treated with AVR for AS compared with the general population.…”