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Coronary Cannulation After TAVR: The RE-ACCESS Study
Quick Takes
- This study reports that in a high-volume TAVR center, 7.7% of patients had an impediment to coronary ostia cannulation post-TAVR.
- Three variables, i.e., use of the Evolut valve, sinus of Valsalva oversizing, and depth of implantation taken together had an excellent discrimination capability to predict unsuccessful coronary cannulation after TAVR.
- A balanced decision-making process for selection of TAVR valve type and size when considering future coronary access is indicated.
Study Questions:
What is the feasibility of coronary ostia cannulation after transcatheter aortic valve replacement (TAVR), and potential predictors of coronary access impairment?
Methods:
The investigators conducted 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. The receiver operating characteristic curve was used to test the sensitivity and specificity of values predicting the nonfeasibility of coronary cannulation.
Results:
Among 300 patients enrolled in the RE-ACCESS (Reobtain Coronary Ostia Cannulation Beyond Transcatheter Aortic Valve Stent) study from December 2018–January 2020, a total of 23 (7.7%) cases 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). At multivariate analysis, the use of Evolut R/PRO TAVs (odds ratio [OR], 29.6; 95% confidence interval [CI], 2.6–335.0; p < 0.01), the TAV/sinus of Valsalva relation (OR, 1.1 per 1 mm increase; 95% CI, 1.0–1.2; p < 0.01), and the mean TAV implant depth (OR, 1.7 per 1 mm decrease; 95% CI, 1.3–2.3; p < 0.01) were found to be independent predictors of unsuccessful coronary cannulation after TAVR. A model combining these factors demonstrated to predict with very high accuracy the risk of unsuccessful coronary cannulation after TAVR (area under the curve, 0.94; p < 0.01).
Conclusions:
The authors concluded that unsuccessful coronary cannulation following TAVR was observed in 7.7% of patients and occurred almost exclusively in patients receiving Evolut TAV.
Perspective:
This study reports that in a high-volume TAVR center, 7.7% of patients had an impediment to coronary ostia cannulation post-TAVR compared with no cases of unsuccessful cannulation before TAVR. Unsuccessful cannulation occurred almost exclusively in patients undergoing Evolut valve implantation. Furthermore, three variables, i.e., use of the Evolut valve, sinus of Valsalva oversizing, and depth of implantation taken together had an excellent discrimination capability to predict unsuccessful coronary cannulation after TAVR. These and other available data suggest a need for a balanced decision-making process for selection of TAVR valve type, size, and implantation depth when considering future coronary re-access.
Clinical Topics: Cardiac Surgery, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Prevention, Valvular Heart Disease, Atherosclerotic Disease (CAD/PAD), Aortic Surgery, Cardiac Surgery and Arrhythmias, Cardiac Surgery and VHD, Interventions and Coronary Artery Disease, Interventions and Imaging, Interventions and Structural Heart Disease, Angiography, Nuclear Imaging
Keywords: Aortic Valve Stenosis, Cardiac Surgical Procedures, Catheterization, Coronary Angiography, Coronary Artery Disease, Heart Valve Diseases, Heart Valve Prosthesis Implantation, Secondary Prevention, Sinus of Valsalva, Stents, Transcatheter Aortic Valve Replacement
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