Toby Rogers1, Benjamin C Greenspun2, Gaby Weissman3, Rebecca Torguson2, Paige Craig2, Christian Shults4, Paul Gordon5, Afshin Ehsan6, Sean R Wilson7, John Goncalves8, Robert Levitt9, Chiwon Hahn10, Puja Parikh11, Thomas Bilfinger12, David Butzel13, Scott Buchanan13, Nicholas Hanna14, Robert Garrett15, Maurice Buchbinder16, Federico Asch17, Hector M Garcia-Garcia17, Petros Okubagzi2, Itsik Ben-Dor2, Lowell F Satler2, Ron Waksman18. 1. Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC; Cardiovascular Branch, Division of Intramural Research, National Heart, Lung, and Blood Institute, National Institutes of Health, Bethesda, Maryland. 2. Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC. 3. Department of Cardiology, MedStar Washington Hospital Center, Washington, DC. 4. Division of Cardiothoracic Surgery, MedStar Washington Hospital Center, Washington, DC. 5. Division of Cardiology, The Miriam Hospital, Providence, Rhode Island. 6. Division of Cardiothoracic Surgery, Lifespan Cardiovascular Institute, Providence, Rhode Island. 7. Department of Medicine, The Valley Hospital, Ridgewood, New Jersey. 8. Cardiac Surgery Program, The Valley Hospital, Ridgewood, New Jersey. 9. Department of Cardiology, Henrico Doctors' Hospital, Richmond, Virginia. 10. Department of Cardiothoracic Surgery, Henrico Doctors' Hospital, Richmond, Virginia. 11. Department of Medicine, Stony Brook Hospital, Stony Brook, New York. 12. Department of Surgery, Stony Brook Hospital, Stony Brook, New York. 13. Cardiovascular Service Line, Maine Medical Center, Portland, Maine. 14. St. John Heart Institute Cardiovascular Consultants, St. John Health System, Tulsa, Oklahoma. 15. St. John Clinic Cardiovascular Surgery, St. John Heart Institute Cardiovascular Consultants, St. John Health System, Tulsa, Oklahoma. 16. Foundation for Cardiovascular Medicine, Stanford University, Stanford, California. 17. MedStar Health Research Institute, MedStar Washington Hospital Center, Washington, DC. 18. Section of Interventional Cardiology, MedStar Washington Hospital Center, Washington, DC. Electronic address: ron.waksman@medstar.net.
Abstract
OBJECTIVES: The aim of this study was to evaluate the feasibility of coronary access and aortic valve reintervention in low-risk patients undergoing transcatheter aortic valve replacement (TAVR) with a balloon-expandable transcatheter heart valve (THV). BACKGROUND: Younger, low-risk TAVR patients are more likely than older, higher risk patients to require coronary angiography, percutaneous coronary intervention, or aortic valve reintervention, but their THVs may impede coronary access and cause coronary obstruction during TAVR-in-TAVR. METHODS: The LRT (Low Risk TAVR) trial (NCT02628899) enrolled 200 subjects with symptomatic severe aortic stenosis to undergo TAVR using commercially available THVs. Subjects who received balloon-expandable THVs and who had 30-day cardiac computed tomographic scans were included in this study. In a subgroup, the feasibility of intentional THV crimping on the delivery catheter to pre-determine commissural alignment was tested. RESULTS: In the LRT trial, 168 subjects received balloon-expandable THVs and had 30-day cardiac computed tomographic scans, of which 137 were of adequate image quality for analysis. The most challenging anatomy for coronary access (THV frame above and commissural suture post in front of a coronary ostium) was observed in 9% to 13% of subjects. Intentional THV crimping did not appear to meaningfully affect commissural alignment. The THV frame extended above the sinotubular junction in 21% of subjects, and in 13%, the distance between the THV and the sinotubular junction was <2 mm, signifying that TAVR-in-TAVR may not be feasible without causing coronary obstruction. CONCLUSIONS: TAVR may present challenges to future coronary access and aortic valve reintervention in a substantial number of low-risk patients.
OBJECTIVES: The aim of this study was to evaluate the feasibility of coronary access and aortic valve reintervention in low-risk patients undergoing transcatheter aortic valve replacement (TAVR) with a balloon-expandable transcatheter heart valve (THV). BACKGROUND: Younger, low-risk TAVR patients are more likely than older, higher risk patients to require coronary angiography, percutaneous coronary intervention, or aortic valve reintervention, but their THVs may impede coronary access and cause coronary obstruction during TAVR-in-TAVR. METHODS: The LRT (Low Risk TAVR) trial (NCT02628899) enrolled 200 subjects with symptomatic severe aortic stenosis to undergo TAVR using commercially available THVs. Subjects who received balloon-expandable THVs and who had 30-day cardiac computed tomographic scans were included in this study. In a subgroup, the feasibility of intentional THV crimping on the delivery catheter to pre-determine commissural alignment was tested. RESULTS: In the LRT trial, 168 subjects received balloon-expandable THVs and had 30-day cardiac computed tomographic scans, of which 137 were of adequate image quality for analysis. The most challenging anatomy for coronary access (THV frame above and commissural suture post in front of a coronary ostium) was observed in 9% to 13% of subjects. Intentional THV crimping did not appear to meaningfully affect commissural alignment. The THV frame extended above the sinotubular junction in 21% of subjects, and in 13%, the distance between the THV and the sinotubular junction was <2 mm, signifying that TAVR-in-TAVR may not be feasible without causing coronary obstruction. CONCLUSIONS: TAVR may present challenges to future coronary access and aortic valve reintervention in a substantial number of low-risk patients.
Authors: Toby Rogers; Jaffar M Khan; Lowell F Satler; Adam B Greenbaum; Robert J Lederman Journal: J Am Coll Cardiol Date: 2020-08-25 Impact factor: 24.094
Authors: Won-Keun Kim; Matthias Renker; Oliver Doerr; Simon Hofmann; Holger Nef; Yeong-Hoon Choi; Christian W Hamm Journal: Clin Res Cardiol Date: 2021-09-02 Impact factor: 5.460
Authors: Arif A Khokhar; Francesco Ponticelli; Adriana Zlahoda-Huzior; Kailash Chandra; Rossella Ruggiero; Marco Toselli; Francesco Gallo; Alberto Cereda; Alessandro Sticchi; Alessandra Laricchia; Damiano Regazzoli; Antonio Mangieri; Bernhard Reimers; Simone Biscaglia; Carlo Tumscitz; Gianluca Campo; Ghada W Mikhail; Won-Keun Kim; Antonio Colombo; Dariusz Dudek; Francesco Giannini Journal: Front Cardiovasc Med Date: 2022-09-14