BackgroundCoronary access (CA) and percutaneous coronary intervention (PCI) might be challenging after valve-in-valve (ViV) transcatheter aortic valve replacement (TAVR) with supra-annular self-expanding valves (SS-TAVs) in surgical aortic valves (SAVs). Our study aim was to compare feasibility, predictors and techniques of CA and PCI following ViV-TAVR with ACURATE neo2 (Boston Scientific, Marlborough) and Evolut PRO+ (Medtronic, Minneapolis, Minnesota). MethodsFifteen computed tomography (CT)-based patient-specific aortic models were 3D-printed and implanted with specific SAVs and with the two SS-TAVs with commissural alignment. Two operators attempted CA (n=120) and PCI (n=120) of each coronary artery in a pulsatile-flow-simulator, under real catheterization laboratory conditions. The primary endpoints were the rate of successful CA and PCI. Outcomes with different SS-TAVs were directly compared. An internally mounted borescope camera was utilized to assess procedures. CT of the models was obtained. ResultsACURATE neo2 showed significantly higher rates of successful CA (96.7%vs.75%, p=0.001) and PCI (98.3%vs.85%, p=0.008), and was associated with a shorter procedural time as compared to Evolut PRO+. Independent predictors of unsuccessful CA and PCI were smaller SAV size and Evolut PRO+. The advantage of ACURATE neo2 was mediated by a larger valve-to-anatomy distance at the top of the leaflet plane (11.3vs.4.8 mm), facilitating more often an external cannulation approach for both CA (36.7%vs.15%, p<0.001) and PCI (36.7%vs.21.7%, p=0.013). ConclusionsThe rate of successful CA and PCI following ViV-TAVR was higher with ACURATE neo2 as compared to Evolut PRO+. The differences in SS-TAVs design impacted the cannulation approach and subsequent procedural outcomes.