Interventions for valvular disease and heart failure

Lifetime management of patients with symptomatic severe aortic stenosis: a computed tomography simulation study

EuroIntervention 2022;18:e407-e416. DOI: 10.4244/EIJ-D-21-01091

Giorgio Medranda
Giorgio A. Medranda1, MD; Cesar E. Soria Jimenez2, MD; Rebecca Torguson3, MPH; Brian C. Case1, MD; Brian J. Forrestal1, MBBS; Syed W. Ali1, MBBS; Corey Shea1, MS; Cheng Zhang1, PhD; John C. Wang4, MD; Paul Gordon5, MD; Afshin Ehsan6, MD; Sean R. Wilson7, MD; Robert Levitt8, MD; Puja Parikh9, MD; Thomas Bilfinger10, MD, ScD; Nicholas Hanna11, MD; Maurice Buchbinder12, MD; Federico M. Asch13, MD; Gaby Weissman2, MD; Christian C. Shults14, MD; Hector M. Garcia-Garcia1, MD, PhD; Itsik Ben-Dor1, MD; Lowell F. Satler1, MD; Ron Waksman1, MD; Toby Rogers1,15, MD, PhD
1. Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC, USA; 2. Department of Cardiology, MedStar Washington Hospital Center, Washington, DC, USA; 3. The Zena and Michael A. Wiener Cardiovascular Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA; 4. Department of Interventional Cardiology, MedStar Union Memorial Hospital, Baltimore, MD, USA; 5. Division of Cardiology, Miriam Hospital, Providence, RI, USA; 6. Division of Cardiothoracic Surgery, Lifespan Cardiovascular Institute, Providence, RI, USA; 7. Department of Cardiology, North Shore University Hospital, Manhasset, NY, USA; 8. Department of Cardiology, HCA Virginia Health System, Richmond, VA, USA; 9. Department of Medicine, Stony Brook Hospital, Stony Brook, NY, USA; 10. Department of Surgery, Stony Brook Hospital, Stony Brook, NY, USA; 11. St. John Heart Institute Cardiovascular Consultants, St. John Health System, Tulsa, OK, USA; 12. Foundation for Cardiovascular Medicine, Stanford University, Stanford, CA, USA; 13. MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, DC, USA; 14. Department of Cardiac Surgery, MedStar Washington Hospital Center, Washington, DC, USA; 15. Cardiovascular Branch, Division of Intramural Research, National Heart, Lung and Blood Institute, National Institutes of Health, Bethesda, MD, USA

Background: Given enough time, transcatheter heart valves (THVs) will degenerate and may require reintervention. Redo transcatheter aortic valve implantation (TAVI) is an attractive strategy but carries a risk of coronary obstruction.

Aims: We sought to predict how many TAVIs patients could undergo in their lifetime using computed tomography (CT) simulation.

Methods: We analysed paired CT scans (baseline and 30 days post-TAVI) from patients in the LRT trial and EPROMPT registry. We implanted virtual THVs on baseline CTs, comparing predicted valve-to-coronary (VTC) distances to 30-day CT VTC distances to evaluate the accuracy of CT simulation. We then simulated implantation of a second virtual THV within the first to estimate the risk of coronary obstruction due to sinus sequestration and the need for leaflet modification.

Results: We included 213 patients with evaluable paired CTs. There was good agreement between virtual (baseline) and actual (30 days) CT measurements. CT simulation of TAVI followed by redo TAVI predicted low coronary obstruction risk in 25.4% of patients and high risk, likely necessitating leaflet modification, in 27.7%, regardless of THV type. The remaining 46.9% could undergo redo TAVI so long as the first THV was balloon-expandable but would likely require leaflet modification if the first THV was self-expanding.

Conclusions: Using cardiac CT simulation, it is possible to predict whether a patient can undergo multiple TAVI procedures in their lifetime. Those who cannot may prefer to undergo surgery first. CT simulation could provide a personalised lifetime management strategy for younger patients with symptomatic severe aortic stenosis and inform decision-making. NCT02628899; NCT03557242; NCT03423459.

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aortic stenosisdegenerative valvenon-invasive imagingparavalvular leaktavivalve-in-valve
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