High Transcatheter Heart Valve Implant and Coronary Access
- High transcatheter heart valve (THV) implantation compared to conventional implantation was associated with a significant reduction in pacemaker rates (0% vs. 10.8% Evolut; no difference in SAPIEN 3).
- Post-TAVR CT showed that high THV implantation resulted in significant interference with coronary access and increased risk of sinus sequestration in TAVR-in-TAVR.
- Patient-specific THV implantation depth and commissural alignment should be considered to balance the risks of conduction disturbances and unfavorable coronary access after TAVR.
What is the impact of high transcatheter heart valve (THV) implantation on coronary access after transcatheter aortic valve replacement (TAVR)?
Data regarding the impact of high THV implantation on coronary access after TAVR as assessed by post-implantation computed tomography (CT) are scarce. 160 and 258 patients treated with Evolut R/PRO/PRO+ and SAPIEN 3 THVs, respectively, were included in this analysis. In the Evolut R/PRO/PRO+ group, the target implantation depth was 1-3 mm using cusp overlap view with commissural alignment technique for the high implantation technique (HIT), whereas it was 3-5 mm using 3-cusp coplanar view for the conventional implantation technique (CIT). In the SAPIEN 3 group, the HIT employed the radiolucent line-guided implantation, whereas the central balloon marker-guided implantation was used for the CIT. Post-TAVR CT was performed to analyze coronary accessibility.
HIT reduced the incidence of new conduction disturbances after TAVR for both THVs. In the Evolut R/PRO/PRO+ group, post-TAVR CT showed that the HIT group had a higher incidence of the interference of THV skirt (22.0% vs. 9.1%, p = 0.03) and a lower incidence of the interference of THV commissural posts (26.0% vs. 42.7%, p = 0.04) with access to one or both coronary ostia compared with the CIT group. These incidences were similar between the HIT and CIT groups in the SAPIEN 3 group (THV skirt: 0.9% vs. 0.7%, p = 1.00; THV commissural tabs: 15.7% vs. 15.3%, p = 0.93). In both THVs, CT-identified risk of sinus sequestration in TAVR-in-TAVR was significantly higher in the HIT group compared with the CIT group (Evolut R/PRO/PRO+ group: 64.0% vs. 41.8%, p = 0.009; SAPIEN 3 group: 17.6% vs. 5.3%, p = 0.002).
High THV implantation substantially reduced conduction disturbances after TAVR. However, post-TAVR CT revealed that there is a risk for unfavorable future coronary access after TAVR and sinus sequestration in TAVR-in-TAVR.
This important analysis evaluated the impact of high THV implantation techniques on conduction disturbance and subsequent coronary access using both the Evolut and SAPIEN 3 platforms. High implantation compared to conventional implantation was associated with a significant reduction in pacemaker rates (0% vs. 10.8% Evolut; no difference in SAPIEN 3). However, post-TAVR CT showed that high implantation resulted in significant interference with coronary access and risk of sinus sequestration in TAVR-in-TAVR with high implantation. Findings from this study provide important insight to help guide design optimization of future THV platforms and highlight the importance of considering coronary access and need for redo TAVR. Last, findings lend support to tailoring implantation technique based on clinical and anatomical factors to facilitate lifetime management of patients with aortic stenosis.
Clinical Topics: Cardiac Surgery, Cardiovascular Care Team, Heart Failure and Cardiomyopathies, Invasive Cardiovascular Angiography and Intervention, Noninvasive Imaging, Valvular Heart Disease, Aortic Surgery, Cardiac Surgery and Heart Failure, Cardiac Surgery and VHD, Acute Heart Failure, Interventions and Imaging, Interventions and Structural Heart Disease, Computed Tomography, Nuclear Imaging
Keywords: Aortic Valve Stenosis, Cardiac Conduction System Disease, Cardiac Surgical Procedures, Heart Failure, Heart Valve Diseases, Heart Valve Prosthesis Implantation, Pacemaker, Artificial, Tomography, X-Ray Computed, Transcatheter Aortic Valve Replacement
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