Patient-Specific Implantation Technique to Obtain Neo-Commissural Alignment With Self-Expanding Transcatheter Aortic Valves

Coronary access after transcatheter aortic valve replacement in bicuspid versus tricuspid aortic stenosis

BACKGROUND

It is unknown whether there are differences in coronary access after transcatheter aortic valve replacement (TAVR) between bicuspid and tricuspid anatomy.

AIMS

Our aim was to investigate coronary access after TAVR using a self-expanding transcatheter heart valve (THV) in bicuspid versus tricuspid aortic valves (BAV vs TAV), based on CT simulation.

METHODS

A total of 86 type 0 BAV, 70 type 1 BAV, and 132 TAV patients were included. If the coronary ostium faced the sealed parts of the THV or the tilted-up native leaflet (NL), this was defined as THV- or NL-related challenging coronary access, respectively. If coaxial engagement was not allowed due to interference from the unwrapped frame, THV-related complex coronary access was defined.

RESULTS

The incidence of THV-related challenging coronary access was 21.2% for the left coronary artery (LCA) and 17.7% for the right coronary artery (RCA), and type 0 BAV patients encountered fewer THV-related challenging LCA access than their TAV counterparts (OR 0.42, 95% CI: 0.20-0.89). NL-related challenging coronary access was observed in 3.1% for LCA and 1.4% for RCA, and THV-related complex coronary access was identified in 5.9% for LCA and 17.0% for RCA; however, no significant differences were found among groups. The proportion of optimal fluoroscopic viewing angles suitable for guiding LCA engagement was similar among groups (64.0% vs 70.0% vs 62.1%), but those suitable for guiding RCA engagement were significantly higher in the type 0 BAV group (31.4% vs 4.3% vs 9.1%).

CONCLUSIONS

Coronary access may be challenging or complex in a significant proportion of both BAV and TAV patients after TAVR. Type 0 BAV anatomy may be more favourable for post-TAVR coronary access.

Practical Approach to Transcatheter Aortic Valve Implantation and Bioprosthetic Valve Fracture in a Failed Bioprosthetic Surgical Valve

Bioprosthetic surgical aortic valve failure requiring reintervention is a frequent clinical problem with event rates up to 20% at 10 years after surgery. Transcatheter aortic valve-in-valve implantation (ViV-TAVI) has become a valuable treatment option for these patients, although it requires careful procedural planning. We here describe and illustrate a stepwise approach to plan and perform ViV-TAVI and discuss preprocedural computerized tomography planning, transcatheter heart valve selection, and implantation techniques. Particular attention is paid to coronary artery protection and the possible need for bioprosthetic valve fracture since patients with small surgical aortic bioprostheses are at a risk of high residual gradients after ViV-TAVI. Considering updated clinical data on long-term outcomes following ViV-TAVI, this approach may become the default treatment strategy for patients with a failing surgical aortic bioprosthesis.

Cusp Symmetry and Coronary Ostial Eccentricity and its Impact on Coronary Access Following TAVR

OBJECTIVES

The aim of this study was to assess cusp symmetry and coronary ostial eccentricity and its impact on coronary access following transcatheter aortic valve replacement (TAVR) using a patient-specific commissural alignment implantation technique.

BACKGROUND

TAVR implantation techniques to obtain neocommissural alignment have been introduced. The impact of cusp symmetry and coronary ostial eccentricity on coronary access after TAVR remains unknown.

METHODS

Cardiac computed tomographic scans from 200 tricuspid aortic valves (TAVs) and 200 type 1 bicuspid aortic valves (BAVs) were studied. Cusp symmetry and coronary ostial eccentricity were assessed. In addition, the right coronary cusp/left coronary cusp and right coronary artery (RCA)/left coronary artery (LCA) ostia overlap views were calculated and compared.

RESULTS

Severe cusp asymmetry (>135°) was more frequent in BAVs (52.5%) than in TAVs (2.5%) (P < 0.001), with the noncoronary cusp being the most common dominant cusp. The RCA ostium was found to be more often eccentric (>20°) than the LCA ostium (28% vs 6%, respectively; P < 0.001). Considering the right/left cusp overlap view, there was <20° deviation between the right coronary cusp-left coronary cusp centered line and the RCA-LCA centered line in 95% of all patients (TAV, 97%; BAV, 93%). The right/left cusp and coronary ostia overlap view differed by <10° and <20° fluoroscopic angulation in 75% and 98% of all cases, respectively.

CONCLUSIONS

Using the right/left cusp overlap view to obtain commissural alignment in TAVR is also an effective approach to implant one of the transcatheter heart valve commissures in the near center between both coronary ostia in most TAVs and type 1 BAVs. Preprocedural CT assessment remains crucial to assess cusp symmetry and coronary ostial eccentricity.

Intentional Misalignment of a Transcatheter Aortic Valve to Preserve Reaccess to Coronaries of Anomalous Origin

Achieving patient-specific commissural alignment of transcatheter aortic valves is particularly important to ensure coronary reaccess after transcatheter aortic valve implantation. Nevertheless, in case of uncommon origin of coronary arteries, commissural alignment could be counterproductive. This case shows how alignment techniques could serve to intentionally misalign the neocommissures in this subset of patients. (Level of Difficulty: Intermediate.)

Coronary artery cannulation after transcatheter aortic valve implantation

Transcatheter aortic valve implantation (TAVI) has revolutionised the treatment of severe, symptomatic aortic stenosis and it is now a proven and effective alternative to surgery for patients regardless of preoperative risk stratification. Nevertheless, the consequent expansion towards younger patients with longer life expectancy focuses attention on long-term considerations. In particular, although the prevalence of coronary artery disease has been shown to decrease with the lowering of estimated risk stratification, the chance of requirement of future coronary interventions after TAVI increases dramatically as a function of patients' life expectancy. To date, however, only a few studies have investigated the feasibility and reproducibility of coronary artery cannulation after TAVI. Different conditions related mainly to aortic root anatomy and specific transcatheter aortic valve (TAV) designs and deployment have been associated with impaired coronary access after TAVI. In the present review, we will examine the conditions that may make coronary access after TAVI more challenging or even impossible.