OBJECTIVES The aim of this study was to assess coronary accessibility after transcatheter
aortic valve replacement (TAVR)-in-TAVR using multidetector computed tomography.BACKGROUND
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.METHODS 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.RESULTS
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 the neo-skirt, the distance between
the THV and the aortic wall was <3 mm 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
can be expected in 8% and 33% of CV/EV-first and SAPIEN-first cases, respectively
(p = 0.005).CONCLUSIONS Coronary access after TAVR-in-TAVR may be challenging in a
significant proportion of patients. THVs with intra-annular leaflet position or low
commissural height and large open cells may be preferable in terms of coronary access
after TAVR-in-TAVR. (C) 2020 by the American College of Cardiology Foundation.
