Coronary access after transcatheter aortic valve replacement

Coronary artery disease (CAD) and aortic stenosis (AS) often coexist. While the clinical impact of CAD on subjects with AS undergoing transcatheter aortic valve replacement (TAVR) is controversial, current guidelines suggest revascularization of proximal severe CAD before TAVR. This recommendation is mainly based on concerns about the possibility to reaccess the coronary arteries once the transcatheter heart valve (THV) is in place. In fact, previous case series report challenges in cannulation of coronary ostia after TAVR, particularly with self-expandable THVs. These aspects are important as indication to TAVR is moving towards younger patients, who are more likely to need CA, giving the progressive nature of CAD and their longer life expectancy. The first objective of our research was to assess the incidence of coronary access (CA) after TAVR at long-term follow up in a high-volume center, evaluating safety and feasibility of coronary angiography and percutaneous coronary intervention (PCI) after TAVR with different types of THVs. At a median follow up over 3 years, incidence of CA after TAVR was 5.3%. In one out of three patients, indication to CA was an acute coronary syndrome, and PCI was performed in over half of the cases. Independent predictors of CA after TAVR were younger age, previous PCI and CABG. CA of both vessels was feasible in all patients with an intra-annular THV, while the right coronary artery was not engaged in two patients with a supra-annular THV. PCI was successful in all but one case. All-cause mortality tended to be higher for patients needing CA for acute coronary syndrome. Secondly, we evaluated advantages and pitfalls of CA after TAVR in the presence of bicuspid aortic valve (BAV) stenosis. We performed post-TAVR 3-dimensional computed tomography in patients with BAV treated both with balloon-expanding and self-expandable THVs. In this particular anatomical setting, CA after TAVR as advantages and pitfalls. For instance, the potential asymmetrical prosthesis expansion when the rafe is located between the left and right coronary cusp generates a larger free space between the valve frame and the coronary ostia, thereby simplifying CA. On the contrary, the higher implantation of the THV in the setting of BAV represents a potential challenge for CA. Finally, we aimed to assess the feasibility of CA after TAVR-in-TAVR. In fact, as TAVR indication is moving towards patients with longer life expectancy, THV degeneration will be increasingly common. TAVR-in-TAVR is an appealing therapeutic option in this setting, but concerns have been raised about the risk of acute coronary obstruction and the possibility to re-access the coronaries once the second prosthesis is in place. In fact, when the second THV is implanted, the leaflets of the first prosthesis are displaced vertically, creating a cylindric cage which will impair CA and possibly coronary flow. Consequently, there is a risk plane under which the first valve frame will not be crossable after TAVR-in-TAVR. We therefore developed a novel, imaging-based algorithm to predict possible coronary access impairment after TAVR-in-TAVR, based on the way CA is gained after the index TAVR and on the distance between prosthesis frame and aortic wall under the level of the RP. We then tested our hypothesis by performing coronary angiography after TAVR in 137 consecutive patients. According to our algorithm, CA after TAVR-in-TAVR might be impaired in almost 1/3 of patients currently treated by TAVR. This risk appears to be less frequent with intra-annular SAPIEN 3 as compared to supra-annular Evolut R/Pro and Acurate Neo THVs. Implantation of a supra-annular device, female gender and small sino-tubular junction are independent predictors of possible CA impairment after TAVR-in-TAVR. These results, which will need to be validated in clinical practice, are important for patient counseling and prosthesis selection in subjects with longer life expectancy