Coronary Procedures After TAVI With the Self-Expanding Aortic Bioprosthesis Medtronic CoreValve™, Not an Easy Matter

Coronary Events After Transcatheter Aortic Valve Replacement: Insights From the France TAVI Registry

BACKGROUND

The prevalence of coronary artery disease in patients undergoing transcatheter aortic valve replacement (TAVR) is high. Treatment of a coronary events (CE) after TAVR can be technically challenging.

OBJECTIVES

The authors sought to assess the incidence and prognostic impact of CE after TAVR.

METHODS

Patients undergoing TAVR for native aortic stenosis, with balloon-expandable valves (BEV) or self-expandable valves (SEV), included in the France-TAVI registry (Registry of Aortic Valve Bioprostheses Established by Catheter) were studied. The primary endpoint was the rate of first hospitalization for CE at maximal follow-up. The main secondary endpoint was the composite of all-cause mortality or hospitalization for heart failure following CE.

RESULTS

Between 2013 and 2021, 64,660 patients were included (BEV 63.8%, SEV 36.2%). CE occurred in 11.6% of cases (1.5%/y). Previous coronary artery disease and known coronary artery stenosis >50% before TAVR were the main predictors of CE. After CE, the composite endpoint was lower in patients who underwent percutaneous coronary intervention (PCI) compared with those who had only coronary angiography or no intervention (79.6%, 85.2%, and 86.5%, respectively; P = 0.002) and higher in SEV than in BEV patients (85.8% vs 83.8%; P = 0.01). Patients admitted to a TAVR center were more likely to have PCI (OR: 1.20 [95% CI: 1.01-1.42]; P = 0.04), even more so if they had a BEV (OR: 1.42 [95% CI: 1.18-1.71]; P = 0.002).

CONCLUSIONS

The yearly incidence of CE after TAVR is low. In the event of CE, patients who have not undergone PCI have a worse outcome. SEV patients have a higher rate of unfavorable outcomes and are less likely to undergo PCI, especially when admitted to non-TAVR centers.

Evaluation and management of coronary artery disease in transcatheter aortic valve implantation candidates with severe aortic stenosis and coronary artery disease: technology and techniques

INTRODUCTION

Patients with severe aortic stenosis referred for transcatheter aortic valve implantation (TAVI) often present with concomitant coronary artery disease (CAD). The management of CAD in these patients remains a topic of debate, encompassing the evaluation and timing of percutaneous coronary intervention (PCI).

AREAS COVERED

This review article aims to offer an overview of the role of coronary revascularization in TAVI patients, highlighting the advantages and disadvantages of different strategies: PCI before, concomitant with, and after TAVI. Considering that TAVI indications are expanding and patients with low surgical risk are now being referred for TAVI, the rate of PCI among patients undergoing TAVI is expected to increase. Historically, PCI was performed before TAVI. However, there is now a growing trend to defer PCI until after TAVI.

EXPERT OPINION

It is plausible that in the future, there will be an increase in PCI after TAVI due to several factors: first, multiple studies have shown the safety of TAVI even in patients with severe untreated CAD; second, improvements in TAVI device implantation techniques, such as commissural alignment and patient-specific device selection, have improved access to the coronary arteries post-TAVI.

Acute Coronary Syndrome Following Transcatheter Aortic Valve Replacement

Extending the indication of transcatheter aortic valve replacement (TAVR) to younger and lower-risk patients naturally results in longer life expectancy and survival rates after the intervention. The longer life expectancy of these patients leads to an increased possibility of future acute coronary events, necessitating the development of effective and appropriate treatment strategies. Acute coronary syndromes (ACS) in patients with previous TAVR procedures present with modified clinical characteristics when compared to the non-TAVR population. In populations with prior TAVR procedures, plaque rupture remains the main cause of ACS. However, unlike the non-TAVR population, there is an increased frequency of nonatherotrombotic mechanisms, like emboli and mechanical obstruction of coronary ostia by valve components. The main observation related to the treatment of ACS TAVR patients is the significantly lower percentage of patients undergoing invasive management. Furthermore, ACS in TAVR patients is associated with poor prognosis, higher long-term mortality rates, and higher incidence of MACE. It is surprising that considering this significant and increasingly recognized issue, there are only a few studies that have investigated ACS after TAVR. The scope of the present review is to address available data about ACS following TAVR, focusing on incidence, timing, mechanism, and causes. We also examined current knowledge regarding optimal invasive treatment and analyzed short and long-term clinical outcomes.

Evaluation of coronary disease among patients undergoing transcatheter aortic valve implantation: propensity score matching analysis

BACKGROUND

Chronic coronary syndrome (CCS) is common among elderly patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI). Current guidelines recommend performance of percutaneous coronary intervention (PCI) of any > 70% proximal coronary lesions prior to TAVI.

AIMS

To evaluate the outcomes of two diagnostic approaches for CCS clearance pre-TAVI and to determine the reduction in the need of invasive angiography (IA).

METHODS

We investigated 2219 patients undergoing TAVI for severe aortic stenosis at two large centers with different pre-procedural strategies for CCS assessment: pre-TAVI computed tomography angiography (CTA) with selective invasive angiography according to CTA results or mandatory IA. We preformed propensity score matching analysis using a 1:1 ratio. The final study cohort included 870 matched patients. Peri-procedural complications were documented according to the VARC-2 criteria. Mortality rates were prospectively documented.

RESULTS

Mean age of the study population was 82 ± 7, of whom 55% were female. Patients in the IA group had significantly higher rates of pre-TAVI PCI compared to the CTA group (39% vs. 22%, p < 0.001). Following TAVI, peri-procedural myocardial infarction (MI) rates were similar between the two groups (0.3% vs. 0.7%, p value = 0.41), but spontaneous MI were significantly lower among the IA group (0% vs. 1.3%, p value = 0.03). Kaplan-Meier's survival analysis found that the cumulative probability of 1-year morality was similar between the two groups (p value log rank = 0.65). Cox regression analysis did not find association between CCS clearance strategy and outcome.

CONCLUSIONS

In elderly patients, CTA-driven approach for CCS evaluation pre-TAVI is a valid strategy with similar outcome as compared to invasive approach. CTA strategy significantly reduces invasive procedures rates without compromising patient's outcome.

Commissural alignment in the Evolut TAVR procedure: conventional versus hat marker-guided shaft rotation methods

Background

Coronary cannulation after TAVR is sometimes difficult due to an overlap between native and neo-commissures, especially in Evolut devices with a supra-annular position. The Evolut C-tab corresponds to a neo-commissure, and the hat marker is in a fixed position. Therefore, the orientation of the hat marker can be adjusted to minimise overlaps.

Aims

We investigated whether the HAt marker-guided SHaft rotation method (HASH, stylised as the #rotation method) is effective in facilitating coronary artery access after transcatheter aortic valve replacement (TAVR) with an Evolut system.

Methods

We retrospectively analysed 95 patients who underwent electrocardiogram-gated cardiac computed tomography after TAVR. In the #rotation method, the hat marker of the delivery catheter was adjusted to face the greater curvature of the descending thoracic aorta in the left anterior oblique view. Its orientation was maintained while the system passed through the aortic arch.

Results

In total, 60 and 35 patients underwent TAVR with the #rotation and non-#rotation methods, respectively. A ±15° angle between the native and neo-commissures was more frequent in the #rotation group (p=0.001). Favourable angles and appropriate frame orientation for access to the left coronary artery were significantly more frequent in the #rotation group than in the non-#rotation group (p<0.001 and p=0.001). Although the #rotation method showed a higher rate of favourable angles and frames in the right coronary artery, statistically significant differences were not found.

Conclusions

The #rotation method is useful for improving commissural post alignment in TAVR with Evolut devices, especially in the ostium of the left coronary artery.

Coronary angiography and percutaneous coronary intervention after transcatheter aortic valve replacement: Feasibility in clinical practice

INTRODUCTION AND OBJECTIVE

Coronary artery disease is highly prevalent among patients with severe aortic stenosis who undergo transcatheter aortic valve replacement (TAVR). As indications for TAVR are now expanding to younger and lower-risk patients, the need for coronary angiography (CA) and percutaneous coronary intervention (PCI) during their lifetime is expected to increase. The objective of our study was to assess the need for CA and the feasibility of re-engaging the coronary ostia after TAVR.

METHODS

We performed a retrospective analysis of 853 consecutive patients undergoing TAVR between August 2007 and December 2020. Patients who needed CA after TAVR were selected. The primary endpoint was the rate of successful coronary ostia cannulation after TAVR.

RESULTS

Of a total of 31 CAs in 28 patients (3.5% of 810 patients analyzed: 57% male, age 77.8±7.0 years) performed after TAVR, 28 (90%) met the primary endpoint and in three cannulation was semi-selective. All failed selective coronary ostia cannulations occurred in patients with a self-expanding valve. Sixteen (52%) also had indication for PCI, which was successfully performed in all. The main indication for CA was non-ST-elevation acute coronary syndrome (35%, n=11). Two cases of primary PCI occurred without delay. There were no complications reported during or after the procedure.

CONCLUSION

Although CA was rarely needed in patients after TAVR, selective diagnostic CA was possible in the overwhelming majority of patients. PCI was performed successfully in all cases, without complications.

TAVR Interventions and Coronary Access: How to Prevent Coronary Occlusion

Due to technological advancements during the past 20 years, transcatheter aortic valve replacements (TAVRs) have significantly improved the treatment of symptomatic and severe aortic stenosis, significantly improving patient outcomes. The continuous evolution of transcatheter valve models, refined imaging planning for enhanced accuracy, and the growing expertise of technicians have collectively contributed to increased safety and procedural success over time. These notable advancements have expanded the scope of TAVR to include patients with lower risk profiles as it has consistently demonstrated more favorable outcomes than surgical aortic valve replacement (SAVR). As the field progresses, coronary angiography is anticipated to become increasingly prevalent among patients who have previously undergone TAVR, particularly in younger cohorts. It is worth noting that aortic stenosis is often associated with coronary artery disease. While the task of re-accessing coronary artery access following TAVR is challenging, it is generally feasible. In the context of valve-in-valve procedures, several crucial factors must be carefully considered to optimize coronary re-access. To obtain successful coronary re-access, it is essential to align the prosthesis with the native coronary ostia. As part of preventive measures, strategies have been developed to safeguard against coronary obstruction during TAVR. One such approach involves placing wires and non-deployed coronary balloons or scaffolds inside an at-risk coronary artery, a procedure known as chimney stenting. Additionally, the bioprosthetic or native aortic scallops intentional laceration to prevent iatrogenic coronary artery obstruction (BASILICA) procedure offers an effective and safer alternative to prevent coronary artery obstructions. The key objective of our study was to evaluate the techniques and procedures employed to achieve commissural alignment in TAVR, as well as to assess the efficacy and measure the impact on coronary re-access in valve-in-valve procedures.

Management of coronary artery disease in patients with aortic stenosis in the era of transcatheter aortic valve replacement

Aortic stenosis (AS) is a common valve disorder among the elderly, and these patients frequently have concomitant coronary artery disease (CAD). Risk factors for calcific AS are similar to those for CAD. Historically, the treatment of these conditions involved simultaneous surgical replacement of the aortic valve (AV) with coronary artery bypass grafting. Since the advancement of transcatheter AV therapies, there have been tremendous advancements in the safety, efficacy, and feasibility of this procedure with expanding indications. This has led to a paradigm shift in our approach to the patient with AS and concomitant CAD. Data regarding the management of CAD in patients with AS are largely limited to single-center studies or retrospective analyses. This article aims to review available literature around the management of CAD in patients with AS and assist in the current understanding in approaches toward management.

Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery

Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.

Valve-Related Complications in TAVI Leading to Emergent Cardiac Surgery

Transcatheter aortic valve implantation (TAVI) is now a standard procedure for the treatment of symptomatic aortic valve stenosis in many patients. In Germany, according to the annual reports from the German Institute for Quality Assurance and Transparency in Healthcare (Institut für Qualitätssicherung und Transparenz im Gesundheitswesen), the rate of serious intraprocedural complications, such as valve malpositioning or embolization, coronary obstruction, aortic dissection, annular rupture, pericardial tamponade, or severe aortic regurgitation requiring emergency cardiac surgery has decreased markedly in recent years from more than 5.5% in 2012 to 2.0% in 2019. However, with increased use, the total number of adverse events remains about 500 per year, about 100 of which require conversion to sternotomy. These, sometimes, fatal events can occur at any time and are still challenging. Therefore, the interdisciplinary TAVI heart team should be prepared and aware of possible rescue strategies.

Long-term risk of unplanned percutaneous coronary intervention after transcatheter aortic valve replacement

BACKGROUND

Coronary access after transcatheter aortic valve replacement (TAVR) can be challenging and complicate percutaneous coronary intervention (PCI).

AIMS

We aimed to investigate the incidence, characteristics, and predictors of unplanned PCI after TAVR.

METHODS

In a single-centre registry, TAVR candidates were systematically screened for concomitant coronary artery disease (CAD) through the use of coronary angiography prior to TAVR. Rates of unplanned PCI were prospectively collected and independently adjudicated.

RESULTS

Among 3,015 patients undergoing TAVR between August 2007 and December 2020, 67 patients (2.2%) underwent unplanned PCI after TAVR. The indication for unplanned PCI was acute coronary syndrome in more than half of the cases. Patients with unplanned PCI were younger (80.2±6.5 years vs 81.9±6.4 years; p=0.028) and more likely to be male (75% vs 50%; p<0.001) than those without unplanned PCI. In a multivariable analysis, the number of diseased vessels, male sex, and younger age were independently associated with an increased risk of unplanned PCI. The cumulative incidence rates of unplanned PCI at 1, 5, and 10 years were 0.1%, 0.4%, and 0.6% in patients with no CAD at the time of TAVR, 0.7%, 2.5%, and 3.4% in patients with single-vessel disease, and 1.5%, 5.4%, and 7.4% in patients with multivessel disease, respectively.

CONCLUSIONS

The lifetime risk of unplanned PCI after TAVR is low in patients with no CAD at the time of TAVR but accumulates over time in patients with known CAD, particularly multivessel disease.

CLINICALTRIALS

gov: NCT01368250.

Coronary Access After Transcatheter Aortic Valve Replacement With Commissural Alignment: The ALIGN-ACCESS Study

BACKGROUND

Coronary access (CA) after transcatheter aortic valve replacement (TAVR) with supra-annular transcatheter heart valves (THV) can be challenging. Specific Evolut R/Pro and Acurate Neo THVs orientations are associated with reduced neo-commissure overlap with coronary ostia, while SAPIEN 3 THV cannot be oriented. With the ALIGN-ACCESS study (TAVR With Commissural Alignment Followed by Coronary Access), we investigated the impact of commissural alignment on the feasibility of CA after TAVR.

METHODS

We performed coronary angiography after TAVR with intra-annular SAPIEN 3, supra-annular Evolut R/Pro, and Acurate Neo THVs in 206 patients. Evolut THVs were implanted aiming for commissure alignment. Alignment of Acurate Neo was retrospectively assessed in 36, intentionally attempted in 26 cases. The primary end point was the rate of unfeasible and nonselective CA after TAVR.

RESULTS

Thirty-eight percent of patients received SAPIEN 3, 31.1% Evolut Pro/R, 30.1% Acurate Neo THV. Final valve orientation was favorable to commissural alignment in 85.9% of Evolut and 69.4% of Acurate Neo cases (with intentional alignment successful in 88.5%). Selective CA was higher for SAPIEN 3 than for aligned and misaligned supra-annular THVs (95% versus 71% versus 46%, P<0.001). Cannulation of at least one coronary was unfeasible with 11% misaligned supra-annular, 3% aligned supra-annular, and 0% SAPIEN 3 THVs. Independent predictors of unfeasible/nonselective CA were implantation of a misaligned supra-annular THV (odds ratio, 4.59 [95% CI, 1.81-11.61]; P<0.01), sinus of Valsalva height (odds ratio, 0.83 [95% CI, 0.7-0.98]; P=0.03), and THV-sinus of Valsalva relation (odds ratio, 1.06 [95% CI, 1.02-1.1]; P<0.01).

CONCLUSIONS

Commissural alignment improves the rate of selective CA after TAVR with supra-annular THVs. Nevertheless, aligned supra-annular THVs carry higher risk of unfeasible/nonselective CA than SAPIEN 3. Patients with a misaligned supra-annular THV, low sinus of Valsalva, and higher THV-sinus of Valsalva relation are at highest risk of impaired CA after TAVR.

Coronary Artery Disease in Patients Undergoing Transvalvular Aortic Valve Implantation

Coronary artery disease (CAD) is common in patients with severe aortic stenosis. With the advent of transcatheter aortic valve implantation (TAVI) as a therapeutic option, management of CAD in such patients has undergone a revolution. Younger patients are now candidates for treatment, and have a greater life-time probability of requiring post-TAVI coronary access. Considerations include pre-procedural assessment and revascularisation, procedural planning to avoid coronary obstruction as well as optimisation of post-procedural coronary access. The authors review the challenges of managing CAD in TAVI patients, shed light on the evidence base, and provide guidance on how to optimise management.

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.

[Challenges of coronary catheterization after TAVR]

PURPOSE

Coronary catheterization after transcatheter aortic valve implantation (TAVR) may be challenging. The main objective of the study is to assess the feasibility of coronary catheterization and angioplasty according to each type of valve.

PATIENTS AND METHOD

We retrospectively studied coronary angiography or percutaneous angioplasty procedures after TAVR in two different centers. The catheterization success of coronary artery was evaluated according to the quality of engagement in ostium and opacification of the artery. Other indicators were collected including catheters used, fluoroscopy and angiography times, DAP and the volume of the contrast agent.

RESULTS

Among 1512 TAVR procedures, 33 patients were included. The Sapien 3® valve was implanted in 22 patients and the Evolut® in 11 patients (7 Evolut-R® and 4 Evolut Pro®). Coronary angiography with selective or partially selective catheterization has been successfully performed in all patients with a Sapien 3® valve. In the Evolut® group we identified 3 cases of non-selective catheterization for the right coronary and 1 case for the left coronary. Standard Judkins catheters seem to be the most suitable for both types of valve with very good efficiency.

CONCLUSION

The results of our study is promising for the future of TAVR with a coronary catheterization success rate close to 100% with some difficulties for the Evolut® supra-annular valves. Special attention should be paid to the technique of implantation and orientation of cups in the aortic sinus.

The selection of transcatheter heart valves in transcatheter aortic valve replacement

Transcatheter heart valve technology has rapidly progressed since initial approval in the United States. There are currently two widely available transcatheter heart valve delivery systems approved in the US; however limited data exist on optimal device selection for various patient populations. This review explores the characteristics of currently approved transcatheter heart valve systems and scenarios where one valve system may be favored over others. We provide a simplified decision tree for selecting the optimal transcatheter valve system for specific patient-centered characteristics.

Revascularization in the Transcatheter Aortic Valve Replacement Population

Transcatheter aortic valve replacement (TAVR) is a standard treatment option for patients with severe aortic stenosis. Management of concomitant coronary artery disease (CAD) in these patients remains controversial with no randomized clinical trials to guide decision making in this cohort. The role of CAD in TAVR has been difficult to evaluate given the current heterogeneity in defining CAD, and the used methods to assess CAD. Subsequently, the role of coronary revascularization remains individualized and assessed on a case-by-case basis by the heart team. In this article, the authors discuss the rationale and prognostic role of CAD in patients undergoing TAVR.

Role of coronary angiogram before transcatheter aortic valve implantation

BACKGROUND

Coexistent coronary artery disease is commonly seen in patients undergoing transcatheter aortic valve implantation (TAVI). Previous studies showed that pre-TAVI coronary revascularisation was not associated with improved outcomes, challenging the clinical value of routine coronary angiogram (CA).

AIM

To assess whether a selective approach to perform pre-TAVI CA is safe and feasible.

METHODS

This was a retrospective non-randomised single-centre analysis of consecutive patients undergoing TAVI. A selective approach for performing CA tailored to patient clinical need was developed. Clinical outcomes were compared based on whether patients underwent CA. The primary endpoint was a composite of all-cause mortality, myocardial infraction, repeat CA, and re-admission with heart failure.

RESULTS

Of 348 patients (average age 81 ± 7 and 57% male) were included with a median follow up of 19 (9-31) mo. One hundred and fifty-four (44%) patients, underwent CA before TAVI procedure. Patients who underwent CA were more likely to have previous myocardial infarction (MI) and previous percutaneous revascularisation. The primary endpoint was comparable between the two group (22.6% vs 22.2%; hazard ratio 1.05, 95%CI: 0.67-1.64, P = 0.82). Patients who had CA were less likely to be readmitted with heart failure (P = 0.022), but more likely to have repeat CA (P = 0.002) and MI (P = 0.007). In those who underwent CA, the presence of flow limiting lesions did not affect the incidence of primary endpoint, or its components, except for increased rate of repeat CA.

CONCLUSION

Selective CA is a feasible and safe approach. The clinical value of routine CA should be challenged in future randomised trials

Unplanned Percutaneous Coronary Revascularization After TAVR: A Multicenter International Registry

OBJECTIVES

This study sought to evaluate the incidence and causes of percutaneous coronary intervention (PCI) at different time periods following transcatheter aortic valve replacement (TAVR).

BACKGROUND

Coronary artery disease (CAD) and aortic stenosis frequently coexist, but the optimal management of CAD following TAVR remains incompletely elucidated.

METHODS

Patients undergoing unplanned PCI after TAVR were retrospectively included in an international multicenter registry.

RESULTS

Between July 2008 and March 2019, a total of 133 patients (0.9%; from a total cohort of 15,325) underwent unplanned PCI after TAVR (36.1% after balloon-expandable bioprosthesis, 63.9% after self-expandable bioprosthesis). The median time to PCI was 191 days (interquartile range: 59 to 480 days). The daily incidence of PCI was highest during the first week after TAVR and then declined over time. Overall, the majority of patients underwent PCI due to an acute coronary syndrome, and specifically 32.3% had non-ST-segment elevation myocardial infarction, 15.4% had unstable angina, 9.8% had ST-segment elevation myocardial infarction, and 2.2% had cardiac arrest. However, chronic coronary syndromes are the main indication beyond 2 years. PCI success was reported in almost all cases (96.6%), with no significant differences between patients treated with balloon-expandable and self-expandable bioprostheses (100% vs. 94.9%; p = 0.150).

CONCLUSIONS

Unplanned PCI after TAVR is rare, with an incidence declining over time after TAVR. The main indication to PCI is acute coronary syndrome in the first 2 years after TAVR, and thereafter chronic coronary syndromes become prevalent. Unplanned PCIs are frequently successfully performed after TAVR, with no apparent differences between balloon-expandable and self-expandable bioprostheses. (Revascularization After Transcatheter Aortic Valve Implantation [REVIVAL]; NCT03283501).

The need for future coronary access following surgical or transcatheter aortic valve replacement

The aim of the study was to estimate the percentage of Medicare patients needing coronary access for percutaneous coronary intervention (PCI) or coronary angiography following aortic valve replacement (AVR). Indications for TAVR have expanded to include younger and low-risk patients, raising the question of coronary access for future procedures. Medicare patients <80 years old with an AVR between 2011 and 2018 were included. Time-to-event analyses were conducted using Cox hazard models to estimate risk of coronary access up to 7 years after AVR. Model adjustments included age, sex, race, region, comorbidity, concomitant CABG, and smoking. A total of 13,469 Medicare patients (mean age 70.6) met inclusion criteria. Models estimated that 2.5% of patients at 1-year post-index and 17% at over 7 years would need coronary access. For patients who had SAVR (with or without CABG), estimates for coronary access were similar and over 15% after 6.5 years. For TAVR patients, with a previous PCI, 28% at 4.5 years required coronary access, which was higher than TAVR patients without a previous PCI. SAVR patients with and without CAD at baseline were similar; however, TAVR patients with CAD had a 22% rate of coronary access versus 7% for those without at 3 years. Approximately half of patients who needed coronary access returned to the same hospital as their initial AVR. Coronary access is required in a substantial portion of AVR patients especially those with PCI or a history of CAD undergoing TAVR. The need for coronary access may increase as transcatheter AVR becomes accessible to younger patients with a longer life expectancy.

Feasibility of Coronary Access in Patients With Acute Coronary Syndrome and Previous TAVR

OBJECTIVES

The aim of this study was to characterize the feasibility of coronary angiography (CA) and percutaneous coronary intervention (PCI) in acute settings among patients who have undergone transcatheter aortic valve replacement (TAVR).

BACKGROUND

Impaired coronary access after TAVR may be challenging and particularly in acute settings could have deleterious consequences.

METHODS

In this international registry, data from patients with prior TAVR requiring urgent or emergent CA were retrospectively collected. A total of 449 patients from 25 sites with acute coronary syndromes (89.1%) and other acute cardiovascular situations (10.9%) were included.

RESULTS

Success rates were high for CA of the right coronary artery (98.3%) and left coronary artery (99.3%) and were higher among patients with short stent-frame prostheses (SFPs) than in those with long SFPs for CA of the right coronary artery (99.6% vs 95.9%; P = 0.005) but not for CA of the left coronary artery (99.7% vs 98.7%; P = 0.24). PCI of native coronary arteries was successful in 91.4% of cases and independent of valve type (short SFP 90.4% vs long SFP 93.4%; P = 0.44). Guide engagement failed in 6 patients, of whom 3 underwent emergent coronary artery bypass grafting and another 3 died in the hospital. Among patients requiring revascularization of native vessels, independent predictors of 30-day all-cause mortality were prior diabetes, cardiogenic shock, and failed PCI but not valve type or success of coronary engagement.

CONCLUSIONS

CA or PCI after TAVR in acute settings is usually successful, but selective coronary engagement may be more challenging in the presence of long SFPs. Among patients requiring PCI, prior diabetes, cardiogenic shock, and failed PCI were predictors of early mortality.

Real world coronary artery ostia full accessibility after last generation transcatheter aortic valve implantation

AIM

We evaluate, performing a pooled meta-analysis, the current coronary artery accessibility rate in transcatheter aortic valve implantation (TAVI) patients during the follow-up. Full coronary artery accessibility after TAVI has not been adequately addressed by the current literature.

METHODS

According to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines, data on coronary artery access were obtained from the ratio between in the full coronary engagement (n) and the number of coronary angiography and/or percutaneous coronary intervention (N). Data were synthesized using random-effects meta-analyses.

RESULTS

Out of 7048 TAVI patients, 276 (3.9%) (mean age 76.8 years, 111 (40.2%) females) were analysed. Full coronary artery accessibility for coronary angiographies and percutaneous coronary interventions were obtained in 83.0% (95% confidence interval (CI): 0.66-0.92, p = 0.001, I²: 88.2%) and 96.0% (95% CI: 0.90-0.98, p < 0.0001, I²: 0) of cases (p for difference  < .0.001). Left coronary artery (n = 219) was easily fully engaged compared to the right one (90.9% (95% CI: 0.80-0.96, p < 0.0001, I²: 58.4% and 82.0% (95% CI: 0.60-0.93, p = 0.006, I²: 83.2%), respectively, (p for difference  < 0.001). Using age as moderator variable, meta-regression revealed a positive and negative correlation with coronary artery accessibility in patients treated with Sapien-Edwards (p = 0.008) and CoreValve (p = 0.010) platforms, respectively. Conversely, a negative correlation (p = 0.01) was found between coronary artery accessibility and mean time after Sapien-Edwards platform implantation (p = 0.01).

CONCLUSIONS

Full coronary artery accessibility during coronary angiographies and/or percutaneous coronary interventions results suboptimal for both coronary artery ostia and worse for right compared to left coronary artery after TAVI.

Percutaneous Coronary Intervention in Transcatheter Aortic Valve Implantation Patients: Overview and Practical Management

Coronary artery disease (CAD) is present in 40-75% of patients undergoing transcatheter aortic valve implantation (TAVI) for severe symptomatic aortic stenosis. Currently, the indication for TAVI is expanding toward younger patients at lower surgical risk. Given the progressive nature of CAD, the necessity for coronary angiography (CA), including percutaneous coronary intervention (PCI), will subsequently increase as in the future TAVI patients will be younger and have a longer life expectancy. Data on the impact of PCI in patients with severe CAD scheduled for TAVI are controversial, and although European and US guidelines recommend PCI before TAVI, the optimal timing for PCI remains unclear due to a lack of evidence. Depending on the valve type, position, and axial alignment of the implanted device, CA and/or PCI after TAVI can be challenging. Hence, every interventionalist should be familiar with the different types of transcatheter heart valves and their characteristics and technical issues that can arise during invasive coronary procedures. This review provides an overview of current data regarding the prevalence and clinical implications of CAD and PCI in TAVI patients and includes useful guidance for practical management in the clinical routine.

Pathophysiology, Diagnosis, and Treatment of Patients with Concomitant Severe Aortic Stenosis and Coronary Artery Disease: A Closer Look to the Unresolved Perplexity

Degenerative aortic stenosis (AS) and coronary artery disease (CAD) are the most prevalent cardiovascular diseases in developed countries, and they coexist in up to 50% of patients. The pathophysiological rationale behind concomitant AS and CAD is discussed in detail in this review, together with prognostic implications. Detecting CAD in patients with AS may be challenging, as AS may mask the existence and symptoms of CAD. The safety and reliability of invasive and non-invasive physiological assessment for epicardial coronary disease are also a matter of debate. Finally, the selection and timing of optimal treatment of CAD in patients with severe AS are still unclear. Given the aging of the population, the increase in the prevalence of AS, and the ongoing paradigm shift in its treatment, controversies in the diagnosis and treatment of CAD in the setting of AS are deemed to grow in importance. In this paper, we present contemporary issues in the diagnosis and management of CAD in patients with severe AS who are transcatheter aortic valve implantation (TAVI) candidates and provide perspective on the treatment approach.

Risk of Coronary Obstruction and Feasibility of Coronary Access After Repeat Transcatheter Aortic Valve Replacement With the Self-Expanding Evolut Valve: A Computed Tomography Simulation Study

BACKGROUND

The supra-annular leaflet position and tall stent frame of the self-expanding Evolut PRO or Evolut PRO+ transcatheter heart valves (THVs) may cause coronary occlusion during transcatheter aortic valve replacement (TAVR)-in-TAVR and present challenges for future coronary access. We sought to evaluate the risk of TAVR-in-TAVR with Evolut PRO or Evolut PRO+ THVs and the feasibility of future coronary access.

METHODS

The CoreValve Evolut PRO Prospective Registry (EPROMPT; NCT03423459) prospectively enrolled patients with symptomatic severe aortic stenosis to undergo TAVR using a commercially available latest generation self-expanding THV at 2 centers in the United States. Computed tomography was performed 30 days after TAVR, which we used to simulate TAVR-in-TAVR with a second Evolut PRO or Evolut PRO+ THV and evaluate for risk of coronary obstruction and feasibility of future coronary access.

RESULTS

Eighty-one patients enrolled with interpretable computed tomography are reported herein. Computed tomography simulation predicted sinus of Valsalva sequestration and resultant coronary obstruction during future TAVR-in-TAVR in up to 23% of patients. Computed tomography simulation predicted that the position of the pinned THV leaflets would hinder future coronary access in up to 78% of patients after TAVR-in-TAVR.

CONCLUSIONS

Further THV design improvements and leaflet modification strategies are needed to mitigate the risk of coronary obstruction during TAVR-in-TAVR with self-expanding THVs and to facilitate future coronary access. Registration: URL: https://www.clinicaltrials.gov. Unique identifier: NCT03423459.

Overcoming the transcatheter aortic valve replacement Achilles heel: coronary re-access

Transcatheter aortic valve replacement (TAVR) is an alternative to surgical aortic valve replacement (SAVR) for the treatment of symptomatic severe aortic stenosis (AS). Coronary artery disease (CAD) is common in patients with severe AS. As the indications for TAVR extend to lower risk patients with longer life expectancy and as CAD is a progressive condition, coronary angiography will become increasingly common in patients who have had a previous TAVR. Coronary artery re-access after TAVR may be challenging but is possible in most cases. Commissural alignment of the prosthesis with the native coronary ostia plays an important role in successful coronary re-access. Coronary artery obstruction is a potentially devastating complication of TAVR, particularly in valve-in-valve procedures. In the present keynote lecture, we review techniques used to mitigate the risk of coronary obstruction, as well as catheter selection and strategies for selective coronary artery engagement for specific transcatheter aortic valve (TAV) bioprostheses.

Coronary Cannulation After Transcatheter Aortic Valve Replacement: The RE-ACCESS Study

OBJECTIVES

The aims of this study were to investigate the feasibility of coronary ostia cannulation after transcatheter aortic valve replacement (TAVR) and to assess potential predictors of coronary access impairment.

BACKGROUND

Certain data concerning the feasibility and reproducibility of coronary cannulation after TAVR are lacking.

METHODS

RE-ACCESS (Reobtain Coronary Ostia Cannulation Beyond Transcatheter Aortic Valve Stent) was an investigator-driven, single-center, prospective, registry-based study that enrolled consecutive patients undergoing TAVR using all commercially available devices. All patients underwent coronary angiography before and after TAVR. The primary endpoint was the rate of unsuccessful coronary ostia cannulation after TAVR. Secondary endpoints were the identification of factors associated with the inability to selectively cannulate coronary ostia after TAVR.

RESULTS

Among 300 patients enrolled in the RE-ACCESS study from December 2018 to January 2020, a total of 23 cases (7.7%) of unsuccessful coronary cannulation after TAVR were documented. This issue occurred in 22 of 23 cases with the use of Evolut R/PRO transcatheter aortic valves (TAVs) (17.9% vs. 0.4%; p < 0.01). In multivariate analysis, the use of Evolut R/PRO TAVs (odds ratio [OR]: 29.6; 95% confidence interval [CI]: 2.6 to 335.0; p < 0.01), the TAV-sinus of Valsalva relation (OR: 1.1 per 1-mm increase; 95% CI: 1.0 to 1.2; p < 0.01), and the mean TAV implantation depth (OR: 1.7 per 1-mm decrease; 95% CI: 1.3 to 2.3; p < 0.01) were found to be independent predictors of unsuccessful coronary cannulation after TAVR. A model combining these factors was demonstrated to predict with very high accuracy the risk for unsuccessful coronary cannulation after TAVR (area under the curve: 0.94; p < 0.01).

CONCLUSIONS

Unsuccessful coronary cannulation following TAVR was observed in 7.7% of patients and occurred almost exclusively in those receiving Evolut TAVs. The combination of Evolut TAV, a higher TAV-sinus of Valsalva relation, and implantation depth predicts with high accuracy the risk for unsuccessful coronary cannulation after TAVR. (Reobtain Coronary Ostia Cannulation Beyond Transcatheter Aortic Valve Stent [RE-ACCESS]; NCT04026204).

Low Rate of Invasive Coronary Angiography Following Transcatheter Aortic Valve Implantation: Real-World Prospective Cohort Findings

AIM

To evaluate the real need for coronary access after transcatheter aortic valve implantation (TAVI).

METHODS AND RESULTS

Prospective observational single-center registry, including 563 consecutive patients who underwent TAVI between April 2008 and November 2018, with both self- and balloon-expandable valves in a tertiary European center. Mean age was 82.4 ± 6.9 years, 53.3% were female, 16% had previous history of coronary artery bypass grafting, 33% of previous percutaneous coronary intervention (PCI), and 16.6% of myocardial infarction (MI). Twenty-four percent of the patients were revascularized within one year before TAVI in preparation for the procedure. Median Society of Thoracic Surgeons score was 4.82 (IQ 2.84). In a median follow-up of 24 months (IQ 21.5), 18 patients (3.2%) were identified as potentially in need for invasive coronary angiography: 9 (1.6%) in the setting of stable coronary artery disease and 9 (1.6%) for an acute coronary syndrome. A total of 11 PCIs were performed in 9 patients, with a complete success rate of 63.6%. Procedures that were unsuccessful or partially unsuccessful were due to the inability to cross the stent or the drug-eluting balloon through the valve struts or misplacement within the coronary artery due to lack of catheter support.

CONCLUSION

In this population, a strategy of previous guideline-directed revascularization before TAVI was associated with a low rate of MI and repeated need of coronary access, with a scattered distribution over time. Assuring future access to coronary arteries in patients at increased risk may depend on the revascularization strategy rather than device selection.

Coronary Artery Disease and Transcatheter Aortic Valve Replacement: JACC State-of-the-Art Review

About one-half of transcatheter aortic valve replacement (TAVR) candidates have coronary artery disease (CAD), and controversial results have been reported regarding the effect of the presence and severity of CAD on clinical outcomes post-TAVR. In addition to coronary angiography, promising data has been recently reported on both the use of computed tomography angiography and the functional invasive assessment of coronary lesions in the work-up pre-TAVR. While waiting for the results of ongoing randomized trials, percutaneous revascularization of significant coronary lesions has been the routine strategy in TAVR candidates with CAD. Also, scarce data exists on the incidence, characteristics, and management of coronary events post-TAVR, and increasing interest exist on potential coronary access challenges in patients requiring coronary angiography/intervention post-TAVR. This review provides an updated overview of the current landscape of CAD in TAVR recipients, focusing on its prevalence, clinical impact, pre- and post-procedural evaluation and management, unresolved issues and future perspectives.

Complexity assessment and technical aspect of coronary angiogram and percutaneous coronary intervention following transcatheter aortic valve implantation

BACKGROUND

Performing selective coronary angiogram (CA) and percutaneous coronary intervention (PCI) post transcatheter aortic valve implantation (TAVI) may be challenging with various success rates of coronary ostia engagement.

METHODS

Among all patients who underwent CA and/or PCI after TAVI from our single center TAVI registry, ostia cannulation success was reported according to the quality of ostia engagement and artery opacification, and was classified as either selective, partially selective or non-selective but sufficient for diagnosis.

RESULTS

Among the 424 consecutive TAVI procedures performed at the aforementioned institution, 20 (4.7%) CA were performed in 19 (4.5%) patients at a median time of 464 days post TAVI (25-75% IQ: 213-634 days). CA were performed in 7 CoreValve, 9 Evolut R, 1 Evolut PRO and 2 Edwards Sapien 3 devices. Transradial vascular approach was attempted in 9 procedures (45%, right n = 6 and left n = 3) and was successful in 8 (40%) patients. A total of 20 left main artery ostium cannulation were attempted leading to a diagnostic CA in all of them with selective engagement in 65%. Engagement of the right coronary artery in 2 out of 15 attempted cases failed due to a low ostium in conjunction with a high implantation of a CoreValve prosthesis. 11 PCI (55% of CA) including 2 left main lesions were performed. In 4 patients (36.4% of the PCI), an extension catheter was required to engage the left main. All planned PCI were successful.

CONCLUSIONS

Post TAVI CA and PCI are challenging but feasible even after supra-annular self-expandable valve implantation.

Management of Coronary Artery Disease in the Setting of Transcatheter Aortic Valve Replacement

Aortic stenosis and coronary artery disease (CAD) frequently co-exist, as they share a common pathophysiology and risk factors. Due to lack of randomised controlled trials (RCTs) and exclusion of significant CAD in transcatheter aortic valve replacement (TAVR) trials, the optimal method of revascularisation of CAD in patients undergoing TAVR remains unknown. Observational studies and meta-analyses have shown varied results in outcomes for patients with CAD undergoing TAVR, and no significant difference in post-TAVR outcomes in patients who underwent revascularisation either prior to or during TAVR versus those who did not. However, some observational studies have shown that patients with lower residual SYNTAX score (rSS) post-revascularisation have better outcomes post-TAVR compared to those with higher rSS. RCTs are needed to clearly understand whether revascularisation is beneficial in these patients. Until then, management of CAD in patients undergoing TAVR must be individualised based on discussion with the heart team.

Percutaneous access to coronary arteries in patients after transcatheter aortic valve implantation procedures - is it a real problem?

Transcatheter aortic valve implantation (TAVI) is still developing and changing our approach to treating patients with severe symptomatic aortic stenosis. Aortic stenosis frequently coexists with coronary artery disease. Both diseases have similar risk factors for their development and one should expect a future progression of coronary artery disease. The current guidelines have expanded TAVI indications to include intermediate-risk patients, and perhaps they will be expanded to include low-risk patients in the future. Survival after TAVI in younger patients will depend on the durability of the aortic valves and methods of coronary artery disease treatment. This paper presents some aspects of performing coronary angiography and percutaneous coronary intervention in patients who had TAVI performed using the two most popular aortic valves – balloon expandable aortic valves (Edward Sapien/Edward Sapien XT/Sapien 3) and self-expandable aortic valves (CoreValve/Evolut R) – on the basis of several examples. This paper also focuses on technical aspects associated with a proper implantation of aortic valves to ensure easy access to coronary arteries, as well as on possible problems when the implantation is not optimal. We discuss interactions between the structure of the aortic valve stent, catheters, commissures of new aortic valves, and coronary ostia.

Clinical and Technical Characteristics of Coronary Angiography and Percutaneous Coronary Interventions Performed before and after Transcatheter Aortic Valve Replacement with a Balloon-Expandable Valve

Objectives

To report on the feasibility and technical differences between coronary procedures performed before and after TAVR with the balloon-expandable Edwards-SAPIEN or the SAPIEN XT valves.

Background

Coronary artery disease (CAD) and aortic stenosis often coexist. Transcatheter aortic valve replacement (TAVR) is emerging as a treatment for younger and lower surgical risk patients who might not present with clinically evident CAD before TAVR. The demand for performing post-TAVR coronary angiograms (CAs) and percutaneous coronary interventions (PCIs) will thus increase, posing new technical challenges.

Methods

Over 1000 TAVRs were performed at the Quebec Heart and Lung Institute, of which 616 with the abovementioned valves. Of these, 28 patients had an analyzable pre- and post-TAVR CAs and 13 patients had pre- and post-TAVR PCIs performed. Procedural characteristics were gathered from all coronary procedures and subsequently compared amongst the same type of procedure performed at these two distinct time periods.

Results

Neither CAs‐nor PCIs‐performed after valve implantation revealed significant differences regarding arterial access site, catheter diameter, number of diagnostic or guiding catheters used, procedural duration, fluoroscopy time, or achievement of selective coronary injection. Lesion location and classification, as well as the preference of using a drug-eluting stent, remained unchanged. During post-TAVR CA, the amount of contrast delivered and the radiation dose area product were significantly lower compared with pre-TAVR CA values.

Conclusions

Performance of CA and PCI after TAVR with a balloon-expandable valve appears unaffected by its presence.

Coronary Angiography and Percutaneous Coronary Intervention After Transcatheter Aortic Valve Replacement

Transcatheter aortic valve replacement (TAVR) has revolutionized the management of patients with symptomatic severe aortic stenosis, and indications are expanding towards treating younger patients with lower-risk profiles. Given the progressive nature of coronary artery disease and its high prevalence in those with severe aortic stenosis, coronary angiography and percutaneous coronary intervention will become increasingly necessary in patients after TAVR. There are some data suggesting that there are technical difficulties with coronary re-engagement, particularly in patients with self-expanding valves that, by design, extend above the coronary ostia. The authors review the challenges of coronary angiography and percutaneous coronary intervention post-TAVR and examine the geometric interactions between currently approved transcatheter aortic valves and coronary ostia, while providing a practical guide on how to manage these potentially complex situations.

Feasibility of transcatheter aortic valve implantation in patients with coronary heights ≤7 mm: insights from the transcatheter aortic valve implantation Karlsruhe (TAVIK) registry

OBJECTIVES

Transcatheter aortic valve implantation (TAVI) in patients with low coronary heights is generally denied but is not impossible. Information about these high-risk procedures is sparse.

METHODS

Since May 2008, data of more than 3000 patients who had TAVI were prospectively collected in the institutional TAVI Karlsruhe registry. Characteristics, peri- and postoperative outcome of patients with low coronary heights of ≤7 mm were analysed according to the Valve Academic Research Consortium-2.

RESULTS

Eighty-six patients with an average coronary height of 6.4 ± 1.1 mm (mean age 81.0 ± 5.3 years, logistic EuroSCORE I 19.6 ± 13.3%) were treated. TAVI was performed in 72 transfemoral (83.7%) and 14 transapical (16.3%) cases using 44 CoreValve/Evolut R (51.2%), 21 Sapien XT/S3 (24.4%), 14 ACURATE (16.3%), 5 Lotus (5.8%) and 2 Portico (2.3%) prostheses. Ten procedures were valve-in-valve (VinV) TAVI (VinV, 11.6%). The 72-h, 30-day, 1-year and follow-up (3.0 ± 1.6 years) mortality rates were 2.3%, 8.0%, 10.5% and 26.7%, respectively. Within 30 days, 4 cardiac deaths and 3 non-cardiac deaths occurred (4.7% and 3.5%). Three coronary obstructions (3.5%) occurred-2 during VinV TAVI. One patient was connected to extracorporeal circulation that could not be weaned later due to an unsuccessful percutaneous coronary intervention. Another patient, the only conversion (1.2%), required delayed surgical valve replacement. The third patient died of right heart failure after aortic dissection. The procedural success rate was 95.3%. VinV procedures were associated with increased follow-up deaths (P < 0.001; hazard ratio 7.96).

CONCLUSIONS

Coronary-related complications in TAVI procedures in patients with coronary heights ≤7 mm occurred less frequently, but once they occurred, they were serious. These TAVI procedures are feasible, with a high procedural success rate, but meticulous preoperative planning should be mandatory. In VinV procedures, the follow-up mortality rate is increased; therefore, we do not recommend these procedures.

Incidence, Technical Safety, and Feasibility of Coronary Angiography and Intervention Following Self-expanding Transcatheter Aortic Valve Replacement

BACKGROUND

Transcatheter aortic valve replacement (TAVR) is a well-established treatment option for severe aortic stenosis (AS). AS and coronary artery disease frequently coincide, and therefore some patients may require coronary angiography (CAG) and/or intervention (PCI) post-TAVR. Due to valve stent design, most self-expanding prostheses always cover the coronary ostium, and therefore may hinder future access. The objective of this research was to evaluate the incidence, safety and feasibility of CAG/PCI in patients with prior self-expanding TAVR valves.

METHODS

Among 2170 patients (age 82 ± 6 years, 43% male) who underwent TAVR with Corevalve or Evolut prostheses, as part of the Italian CoreValve ClinicalService® framework (data from 13 Italian centers), the occurrence of CAG/PCI following TAVR and periprocedural characteristics were examined.

RESULTS

During median follow-up of 379 days, 41 patients (1.9%) required CAG and/or PCI (total 46; 16 CAG, 14 PCI, 16 both PCI/CAG). 56.5% of the procedures were performed under emergency/urgency settings. Left system coronary angiography was successfully performed in most cases (28/32, 87.5%), while right coronary angiography was successful only in 50.0% (16/32). PCI procedures (20 for left system, 3 for right system, 4 for graft) were successfully performed in 93.3% (28/30) of the procedures. No CAG/PCI procedure-related complications including prosthesis dislodgment or coronary ostium dissection occurred.

CONCLUSIONS

CAG and PCI procedures following CoreValve TAVR is safe and mostly feasible, although the success rate of selective right coronary angiography was relatively low when compared to the left system. Further investigations are required to explore this issue.