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Dvir D, Leon MB, Abdel-Wahab M, Unbehaun A, Kodali S, Tchetche D, Pibarot P, Leipsic J, Blanke P, Gerckens U, Manoharan G, Harari E, Hellou E, Wolak A, Ben-Assa E, Jubeh R, Shuvy M, Koifman E, Klein C, Kempfert J. First-in-Human Dedicated Leaflet Splitting Device for Prevention of Coronary Obstruction in Transcatheter Aortic Valve Replacement. JACC Cardiovasc Interv 2023; 16:94-102. [PMID: 36599593 DOI: 10.1016/j.jcin.2022.10.050] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Revised: 10/11/2022] [Accepted: 10/25/2022] [Indexed: 01/03/2023]
Abstract
BACKGROUND Coronary artery obstruction is a life-threatening complication of transcatheter aortic valve replacement (TAVR) procedures. Current preventive strategies are suboptimal. OBJECTIVES The aim of this study was to describe bench testing and clinical experience with a novel device that splits valve leaflets that are at risk for causing coronary obstruction after TAVR, allowing normal coronary flow. METHODS The ShortCut device was initially tested in vitro and preclinically in a porcine model for functionality and safety. The device was subsequently offered to patients at elevated risk for coronary obstruction. Risk for coronary obstruction was based on computed tomography-based anatomical characteristics. Procedure success was determined as patient survival at 30 days with a functioning new valve, without stroke or coronary obstruction. RESULTS Following a successful completion of bench testing and preclinical trial, the device was used in 8 patients with failed bioprosthetic valves (median age 81 years; IQR: 72-85 years; 37.5% man) at 2 medical centers. A total of 11 leaflets were split: 5 patients (63.5%) were considered at risk for left main obstruction alone, and 3 patients (37.5%) were at risk for double coronary obstruction. All patients underwent successful TAVR without evidence of coronary obstruction. All patients were discharged from the hospital in good clinical condition, and no adverse neurologic events were noted. Procedure success was 100%. CONCLUSIONS Evaluation of the first dedicated transcatheter leaflet-splitting device shows that the device can successfully split degenerated bioprosthetic valve leaflets. The procedure was safe and successfully prevented coronary obstruction in patients at risk for this complication following TAVR.
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Affiliation(s)
- Danny Dvir
- Department of Cardiology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel.
| | - Martin B Leon
- Columbia University Medical Center, NewYork-Presbyterian Hospital, Cardiovascular Research Foundation, New York, USA
| | | | - Axel Unbehaun
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Susheel Kodali
- New York Presbyterian Hospital, Columbia University Medical Center, New York, New York, USA
| | - Didier Tchetche
- Department of Cardiology, Clinique Pasteur, Toulouse, France
| | - Philippe Pibarot
- Department of Cardiology, Quebec Heart and Lung Institute, Laval University, Quebec City, Quebec, Canada
| | - Jonathon Leipsic
- Department of Radiology, University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
| | - Philipp Blanke
- Department of Radiology, University of British Columbia and St. Paul's Hospital, Vancouver, British Columbia, Canada
| | | | - Ganesh Manoharan
- Royal Victoria Hospital and Queens University, Belfast, United Kingdom
| | - Emanuel Harari
- Cardiology Division, Assuta Ashdod Medical Center, Ashdod, Israel
| | - Elias Hellou
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Arik Wolak
- Department of Cardiology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Eyal Ben-Assa
- Cardiology Division, Assuta Ashdod Medical Center, Ashdod, Israel; Ben-Gurion University of the Negev, Beer Sheva, Israel
| | - Rami Jubeh
- Department of Cardiology, Shaare Zedek Medical Center, Jerusalem, Israel
| | - Mony Shuvy
- Department of Cardiology, Shaare Zedek Medical Center and Faculty of Medicine, Hebrew University of Jerusalem, Israel
| | - Edward Koifman
- Meir Medical Center, Kfar Saba, Israel; Tel Aviv University, Tel Aviv, Israel
| | - Christoph Klein
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
| | - Joerg Kempfert
- Department of Cardiothoracic and Vascular Surgery, German Heart Center Berlin, Berlin, Germany
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Kitamura M, Wilde J, Dumpies O, Richter I, Obradovic D, Krieghoff C, Gohmann RF, Majunke N, Desch S, Gutberlet M, Borger M, Marwan M, Thiele H, Holzhey D, Abdel-Wahab M. Risk Assessment of Coronary Obstruction During Transcatheter Aortic Valve Replacement: Insights From Post-BASILICA Computed Tomography. JACC Cardiovasc Interv 2022; 15:496-507. [PMID: 35272774 DOI: 10.1016/j.jcin.2022.01.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/12/2021] [Revised: 12/30/2021] [Accepted: 01/04/2022] [Indexed: 11/27/2022]
Abstract
OBJECTIVES The aim of this study was to examine the predictive value of preprocedural computed tomography (CT)-based risk stratification of coronary obstruction during transcatheter aortic valve replacement (TAVR) on the basis of geometric measurements on postprocedural CT. BACKGROUND Proper patient selection for additional procedures to prevent coronary obstruction during TAVR has not been adequately evaluated. METHODS Pre- and postprocedural computed tomographic scans of 28 patients treated using bioprosthetic or native aortic scallop intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) and TAVR were analyzed. Using the postprocedural computed tomographic images, threatened coronary obstruction (TCO) was defined as: 1) ostial obstruction (adherence of the transcatheter heart valve [THV] to the coronary ostium with leaflet extension above the ostium); and/or 2) sinus sequestration (THV adherence to the sinotubular junction [STJ] with leaflet extension above the STJ) and was substratified into complete and incomplete types. RESULTS A total of 51 leaflets were evaluated (88% surgical tissue valves) after excluding leaflets not visible on CT (n = 5). On postprocedural CT, complete TCO was observed in 25.4% (13 of 51 leaflets). On preprocedural CT, leaflets were at high risk for complete TCO (incidence 53%) if the virtual THV-to-coronary distance (VTC) was <3.0 mm, or if the virtual THV-to-STJ distance (VTSTJ) was <1.0 mm with STJ height - leaflet length <0 mm (leaflet-STJ mismatch). Leaflets were at low risk (incidence 0%) if the VTC was ≥3 mm and VTSTJ was ≥3.0 mm or STJ height - leaflet length was ≥+2.0 mm. Of 28 leaflets treated using BASILICA, complete TCO was seen in 35.7% (n = 10), due to sinus sequestration (100%) with coexisting ostial obstruction (30%). Actual coronary events occurred in 7.1% (n = 2) because of leaflet prolapse, corresponding to an absolute risk reduction by BASILICA of 29% (P = 0.021). CONCLUSIONS Risk assessment of coronary obstruction after TAVR may improve with a multiparametric approach incorporating VTC, VTSTJ, and leaflet-STJ mismatch. BASILICA appeared to reduce actual coronary events even in leaflets with anticipated coronary obstruction.
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Affiliation(s)
- Mitsunobu Kitamura
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Johannes Wilde
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Oliver Dumpies
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Ines Richter
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Danilo Obradovic
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Christian Krieghoff
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Robin F Gohmann
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Nicolas Majunke
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Steffen Desch
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Matthias Gutberlet
- Department of Diagnostic and Interventional Radiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Michael Borger
- Department of Structural Heart Disease/Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Mohamed Marwan
- Department of Cardiology, Friedrich-Alexander-Universität Erlangen-Nürnberg, Erlangen, Germany
| | - Holger Thiele
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - David Holzhey
- Department of Structural Heart Disease/Cardiac Surgery, Heart Center Leipzig at University of Leipzig, Leipzig, Germany
| | - Mohamed Abdel-Wahab
- Department of Structural Heart Disease/Cardiology, Heart Center Leipzig at University of Leipzig, Leipzig, Germany.
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