Interventions for valvular disease and heart failure

A computed tomography study of coronary access and coronary obstruction after redo transcatheter aortic valve implantation

EuroIntervention 2020;16:e1005-e1013. DOI: 10.4244/EIJ-D-20-00475

Nicola Buzzatti
Nicola Buzzatti1; Matteo Montorfano1; Vittorio Romano1; Ole De Backer2; Lars Søndergaard2; Liesbeth Rosseel3; Pal Maurovich-Horvat4; Julia Karady4; Béla Merkely4; Bernard D. Prendergast5; Michele De Bonis1; Antonio Colombo6; Azeem Latib7
1. San Raffaele Scientific Institute, Milan, Italy; 2. Rigshospitalet - University Hospital, Copenhagen, Denmark; 3. Galway University Hospital, Galway, Ireland; 4. Heart and Vascular Center, Semmelweis University, Budapest, Hungary; 5. St. Thomas’ Hospital, London, United Kingdom; 6. Maria Cecilia Hospital, Cotignola, Italy; 7. Montefiore Medical Center, New York, NY, USA

Aims: The aim of this study was to investigate the risk of impaired coronary access and coronary obstruction after redo TAVI.

Methods and results: Post-procedure multidetector computed tomography (MDCT) scans of 221 TAVI recipients were analysed. Increased risk of impaired coronary access was defined as a coronary ostium below the TAVI commissures with a valve-to-aorta distance <2 mm at this level. Increased risk was found in 123 (55.6%) cases: the left main was involved in 109 (49.3%), the right coronary in 79 (35.7%), and both were involved in 65 (29.4%) patients. A small sinotubular junction (STJ width OR 0.68, CI: 0.56-0.81, p<0.001; STJ height OR 0.81, CI: 0.69-0.95, p<0.011) and supra-annular devices (OR 19.8, CI: 6.6-58.8, p<0.001) predicted increased risk. Increased risk of coronary obstruction, defined as a coronary ostium below the TAVI commissures with a valve-to-coronary distance <2 mm, was observed in 14.9% of patients; in 17.2% of cases complete sealing of the STJ would occur.

Conclusions: Post-TAVI MDCT suggested an increased potential risk of impaired coronary access in more than half of the patients should redo TAVI be required, predicted by a small STJ and supra-annular device design. Furthermore, 10-20% of patients presented an increased risk of coronary obstruction. While this theoretical study is hypothesis-generating, it raises concerns that need to be further investigated and addressed before TAVI is extended to patients with longer life expectancy.

Visual summary. Aortic root in native anatomy (A), after TAVI (B) and after redo TAVI (C): small sinotubular junction and high leaflets of the transcatheter heart valve, pushed up and outwards by the second device, are associated with impaired coronary access and perfusion after redo TAVI.

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coronary artery diseasecoronary occlusiontavi
Coronary interventionsInterventions for valvular diseaseSTEMINSTEMIStable CADOther coronary interventionsTAVI
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