TAVR Interventions and Coronary Access: How to Prevent Coronary Occlusion

Abstract

Due to technological advancements during the past 20 years, transcatheter aortic valve replacements (TAVRs) have significantly improved the treatment of symptomatic and severe aortic stenosis, significantly improving patient outcomes. The continuous evolution of transcatheter valve models, refined imaging planning for enhanced accuracy, and the growing expertise of technicians have collectively contributed to increased safety and procedural success over time. These notable advancements have expanded the scope of TAVR to include patients with lower risk profiles as it has consistently demonstrated more favorable outcomes than surgical aortic valve replacement (SAVR). As the field progresses, coronary angiography is anticipated to become increasingly prevalent among patients who have previously undergone TAVR, particularly in younger cohorts. It is worth noting that aortic stenosis is often associated with coronary artery disease. While the task of re-accessing coronary artery access following TAVR is challenging, it is generally feasible. In the context of valve-in-valve procedures, several crucial factors must be carefully considered to optimize coronary re-access. To obtain successful coronary re-access, it is essential to align the prosthesis with the native coronary ostia. As part of preventive measures, strategies have been developed to safeguard against coronary obstruction during TAVR. One such approach involves placing wires and non-deployed coronary balloons or scaffolds inside an at-risk coronary artery, a procedure known as chimney stenting. Additionally, the bioprosthetic or native aortic scallops intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure offers an effective and safer alternative to prevent coronary artery obstructions. The key objective of our study was to evaluate the techniques and procedures employed to achieve commissural alignment in TAVR, as well as to assess the efficacy and measure the impact on coronary re-access in valve-in-valve procedures.

Transcatheter Aortic Valve Replacement for Failed Surgical or Transcatheter Bioprosthetic Valves: A Comprehensive Review

“…The placement of undeployed coronary balloons/stents with the help of guide catheter extensions into the coronary artery at risk before TAVR valve implantation can be performed using the chimney (or snorkel) technique [ 21 , 59 , 64 , 65 , 66 ]. The chimney technique has also proven to be an acceptable bailout technique to re-establish flow through the obstructed coronary artery if an acute coronary obstruction occurs during the TAVR procedure [ 65 , 66 ].…”

“…The placement of undeployed coronary balloons/stents with the help of guide catheter extensions into the coronary artery at risk before TAVR valve implantation can be performed using the chimney (or snorkel) technique [ 21 , 59 , 64 , 65 , 66 ]. The chimney technique has also proven to be an acceptable bailout technique to re-establish flow through the obstructed coronary artery if an acute coronary obstruction occurs during the TAVR procedure [ 65 , 66 ]. Specific orientation and valve commissure alignment during the deployment of a THV are additional techniques to lower the risk of significant coronary obstruction, though with older generation THVs, this was difficult to achieve [ 57 , 67 ].…”

“…The bioprosthetic aortic scallop intentional laceration to prevent iatrogenic coronary obstruction (BASILICA) procedure was introduced to provide a safer option for patients who are at increased risk of coronary obstruction [ 21 , 59 , 60 , 66 , 68 ]. BASILICA is a technique that uses standard cardiac catheterization equipment to deliver radiofrequency energy to native or bioprosthetic aortic valve leaflets to split the leaflet [ 59 ].…”

“…Due to an increased risk of coronary artery obstruction in patients who undergo ViV TAVR, the techniques discussed in addition to new THV technologies are vital to reducing the risk of acute coronary obstruction and preserving coronary access. Commissural alignment is critical for the optimization of THV placement, and by positioning the commissural posts of the THV away from the coronary ostia, the risk of coronary obstruction can be reduced [ 66 , 67 ]. The orientation, size, shape, depth of valve insertion, and force applied during insertion must all be taken into careful consideration to ensure proper commissural alignment during the deployment of a THV [ 66 , 67 ].…”

“…Commissural alignment is critical for the optimization of THV placement, and by positioning the commissural posts of the THV away from the coronary ostia, the risk of coronary obstruction can be reduced [ 66 , 67 ]. The orientation, size, shape, depth of valve insertion, and force applied during insertion must all be taken into careful consideration to ensure proper commissural alignment during the deployment of a THV [ 66 , 67 ]. Newer generation self-expanding THVs contain specific markers to help guide operators to perform correct commissural alignment [ 66 , 67 ].…”