Coronary Protection to Prevent Coronary Obstruction During TAVR

Study Questions:

What is the safety and efficacy of coronary protection (CP) by preventive coronary wiring and stenting across the coronary ostia in patients at high risk of coronary obstruction after transcatheter aortic valve replacement (TAVR)?

Methods:

The investigators collected data retrospectively from a multicenter, international TAVR registry (CORPROTAVR), which included patients undergoing TAVR at high risk of coronary obstruction and who underwent pre-emptive coronary wire protection and eventual stent implantation across the coronary ostia. The objectives of this study were to compare 3-year clinical outcomes in TAVR patients treated with stenting across the coronary ostia versus those who eventually did not receive stents. The primary endpoint of the study was cardiac mortality. Secondary endpoints were all-cause death, myocardial infarction (MI), stroke, or the composite of cardiac death, MI, or stroke. All clinical outcomes were defined according to the Valve Academic Research Consortium (VARC)-2 criteria. Survival analyses and event rates were determined using the Kaplan-Meier method. Hazard ratio (HR) and 95% confidence interval (CI) were determined using Cox regression models. Multivariable analyses were performed using parsimonious models that included potential confounders unevenly distributed across groups.

Results:

Among 236 patients undergoing CP with preventive coronary wiring, 143 eventually had stents implanted across the coronary ostia after valve deployment. At 3-year follow-up, rates of cardiac death were 7.8% in patients receiving stents versus 15.7% in those not receiving stents (adjusted HR, 0.42; 95% CI, 0.14-1.28; p = 0.13). Two (0.9%) had definite stent thrombosis in patients receiving stents, both occurring after TAVR in “valve-in-valve” (VIV) procedures. In patients not receiving stents, there were four (4.3%) delayed coronary occlusions (DCOs) occurring from 5 minutes to 6 hours after wire removal. Three cases occurred in VIV procedures and one in a native aortic valve procedure. Virtual transcatheter valve <4 mm was present in 75.0% of patients with DCO as compared to 30.4% of patients without DCO (p = 0.19).

Conclusions:

The authors concluded that in patients undergoing TAVR at high risk of coronary obstruction, preventive stent implantation across the coronary ostia is associated with good mid-term survival rates and low rates of stent thrombosis.

Perspective:

This registry study reports that 3-year clinical outcomes of patients undergoing CP with stenting across the ostia (although performed infrequently) were in general favorable, with acceptable rates of cardiac mortality, MI, or stroke and very rare stent thrombosis rates. Furthermore, patients managed with CP who did not eventually receive stents presented a considerable risk of DCO and had numerically higher rates of cardiac mortality compared to patients managed with CP receiving stents. These data suggest that coronary stenting across the coronary ostia may be a valid option for TAVR patients at high risk of coronary occlusion, particularly when distance between virtual transcatheter valve and coronary ostia is <4 mm. Given the retrospective registry nature of the current study, additional prospective validation of benefits of CP with stenting across coronary ostia is indicated.

Clinical Topics: Arrhythmias and Clinical EP, Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Prevention, Valvular Heart Disease, SCD/Ventricular Arrhythmias, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Structural Heart Disease

Keywords: Cardiac Surgical Procedures, Coronary Occlusion, Death, Sudden, Cardiac, Heart Valve Diseases, Myocardial Infarction, Secondary Prevention, Stents, Stroke, Thrombosis, Transcatheter Aortic Valve Replacement


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