Coronary Angiography and PCI After TAVR

Authors:
Yudi MB, Sharma SK, Tang GH, Kini A.
Citation:
Coronary Angiography and Percutaneous Coronary Intervention After Transcatheter Aortic Valve Replacement. J Am Coll Cardiol 2018;71:1360-1378.

The following are key points to remember from this review on coronary angiography and percutaneous coronary intervention (PCI) after transcatheter aortic valve replacement (TAVR):

  1. TAVR has revolutionized the management of patients with symptomatic severe aortic stenosis, and indications are currently expanding toward treating younger patients with lower-risk profiles.
  2. Given the progressive nature of coronary artery disease (CAD) and its high prevalence in those with severe aortic stenosis, coronary angiography and PCI will become increasingly necessary in patients after TAVR.
  3. There are data suggesting that there are technical difficulties with coronary engagement, particularly in patients with self-expanding valves that, by design, extend above the coronary ostia.
  4. At this time, patients with CAD undergoing TAVR should be evaluated by a multidisciplinary heart team and receive individualized management based on their clinical and angiographic findings.
  5. Post-TAVR multidetector computed tomography can be helpful to determine the anatomy and approach to coronary reaccess in elective cases.
  6. Given the design of CoreValve (Medtronic), particularly its narrow waist, engagement of the left coronary artery (LCA) typically requires a smaller catheter than usual. For LCA engagement, JL3.5 and JL3.0 catheters can be used for femoral and radial access, respectively. For right coronary artery engagement, JR4 is the catheter of choice.
  7. If selective engagement continues to be problematic, a coronary wire can be used to enter the coronary artery from the aorta, and then it can act as a rail for the guide.
  8. Care should be taken when disengaging the guide, as it can kink during the procedure. Thus, the guide should be disengaged from the ostium, preferably over a wire, before withdrawal through the diamond of the valve frame.
  9. Coronary angiography technique typically does not have to be modified significantly in the presence of a balloon-expandable valve. If there is a problem with selective coronary engagement, the most likely cause is the position of the commissural tab in front of the coronary ostia. In this scenario, placement of the catheter across the adjacent frame is recommended and nonselective angiography is usually diagnostic.
  10. In the future, it would be advantageous if the commissural tabs could be easily identified on fluoroscopy and there was a simple mechanism to align the prosthetic valve commissures with those of the native valve, thus optimizing its placement in relation to the coronary arteries.

Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Computed Tomography, Nuclear Imaging

Keywords: Aortic Valve Stenosis, Cardiac Catheterization, Coronary Angiography, Coronary Artery Disease, Fluoroscopy, Heart Valve Diseases, Multidetector Computed Tomography, Percutaneous Coronary Intervention, Transcatheter Aortic Valve Replacement


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