Coronary Access After TAVR-in-TAVR as Evaluated by Multidetector Computed Tomography

Ole De Backer, Uri Landes, Andreas Fuchs, Sung-Han Yoon, Ole Norling Mathiassen, Alexander Sedaghat, Won-Keun Kim, Thomas Pilgrim, Nicola Buzzatti, Philipp Ruile, Abdallah El Sabbagh, Marco Barbanti, Claudia Fiorina, Luis Nombela-Franco, Arie Steinvil, Ariel Finkelstein, Matteo Montorfano, Pal Maurovich-Horvat, Klaus Fuglsang Kofoed, Philipp BlankeMatjaz Bunc, Franz-Josef Neumann, Azeem Latib, Stephan Windecker, Jan-Malte Sinning, Bjarne Linde Norgaard, Raj Makkar, John G Webb, Lars Søndergaard

66 Citationer (Scopus)


OBJECTIVES: The aim of this study was to assess coronary accessibility after transcatheter aortic valve replacement (TAVR)-in-TAVR using multidetector computed tomography.

BACKGROUND: Expanding TAVR to patients with longer life expectancy may involve more frequent bioprosthetic valve failure and need for redo TAVR. Coronary access after TAVR-in-TAVR may be challenging, particularly as the leaflets from the initial transcatheter heart valve (THV) will form a neo-skirt following TAVR-in-TAVR.

METHODS: In 45 patients treated with different combinations of CoreValve and Evolut (CV/EV) THVs with supra-annular leaflet position and SAPIEN THVs with intra-annular leaflet position, post-TAVR-in-TAVR multidetector computed tomographic scans were analyzed to examine coronary accessibility.

RESULTS: After TAVR-in-TAVR, the coronary arteries originated below the top of the neo-skirt in 90% of CV/EV-first cases compared with 67% of SAPIEN-first cases (p = 0.009). For these coronary arteries originating below the top of the neo-skirt, the distance between the THV and the aortic wall was <3 mm in 56% and 25% of CV/EV-first and SAPIEN-first cases, respectively (p = 0.035). Coronary access may be further complicated by THV-THV stent frame strut misalignment in 53% of CV/EV-in-CV/EV cases. The risk for technically impossible coronary access was 27% and 10% in CV/EV-first and SAPIEN-first cases, respectively (p = 0.121). Absence of THV interference with coronary accessibility can be expected in 8% and 33% of CV/EV-first and SAPIEN-first cases, respectively (p = 0.005).

CONCLUSIONS: Coronary access after TAVR-in-TAVR may be challenging in a significant proportion of patients. THVs with intra-annular leaflet position or low commissural height and large open cells may be preferable in terms of coronary access after TAVR-in-TAVR.

TidsskriftJACC: Cardiovascular Interventions
Udgave nummer21
Sider (fra-til)2528-2538
Antal sider11
StatusUdgivet - 9 nov. 2020


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