Coronary Access After TAVR-in-TAVR as Evaluated by Multidetector Computed Tomography.

Abstract

The aim of this study was to assess coronary accessibility after transcatheter aortic valve replacement (TAVR)-in-TAVR using multidetector computed tomography. Expanding TAVR to patients with longer life expectancy may involve more frequent bioprosthetic valve failure and need for redo TAVR. Coronary access after TAVR-in-TAVR may be challenging, particularly as the leaflets from the initial transcatheter heart valve (THV) will form a neo-skirt following TAVR-in-TAVR. In 45 patients treated with different combinations of CoreValve and Evolut (CV/EV) THVs with supra-annular leaflet position and SAPIEN THVs with intra-annular leaflet position, post-TAVR-in-TAVR multidetector computed tomographic scans were analyzed to examine coronary accessibility. After TAVR-in-TAVR, the coronary arteries originated below the top of the neo-skirt in 90% of CV/EV-first cases compared with 67% of SAPIEN-first cases (p=0.009). For these coronary arteries originating below the top of theneo-skirt, the distance between the THV and the aortic wall was<3mm in 56% and 25% of CV/EV-first and SAPIEN-first cases, respectively (p=0.035). Coronary access may be further complicated by THV-THV stent frame strut misalignment in 53% of CV/EV-in-CV/EV cases. The risk for technically impossible coronary access was 27% and 10% in CV/EV-first and SAPIEN-first cases, respectively (p=0.121). Absence of THV interference with coronary accessibility canbe expected in 8% and 33% of CV/EV-first and SAPIEN-first cases, respectively (p=0.005). Coronary access after TAVR-in-TAVR may be challenging in a significant proportion of patients. THVswith intra-annular leaflet position or low commissural height and large open cells may be preferable intermsofcoronary access after TAVR-in-TAVR.