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

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  • 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 Blanke
  • Matjaz Bunc
  • Franz-Josef Neumann
  • Azeem Latib
  • Stephan Windecker
  • Jan-Malte Sinning
  • Bjarne Linde Norgaard
  • Raj Makkar
  • John G Webb
  • Lars Søndergaard
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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.

Original languageEnglish
JournalJACC: Cardiovascular Interventions
Volume13
Issue number21
Pages (from-to)2528-2538
Number of pages11
ISSN1936-8798
DOIs
Publication statusPublished - 9 Nov 2020

ID: 61826917