a growing conundrum; coronary access after tavr ......a growing conundrum; coronary access after...
TRANSCRIPT
V. Voudris MD PhD FESC FACC
Director Interventional Cardiology Division
Chairman Cardiology Department
Onassis Cardiac Surgery Center
A Growing Conundrum; Coronary Access After TAVR Difficulties, Tips and Tricks
Disclosures
Consulting Fees / Honoraria :
Medtronic
➢ Transcatheter Aortic Valve Replacement (TAVR) is now the standard of care for patients who are not surgical candidates, and is comparable to surgical aortic valve replacement (SAVR) in high-and intermediate- risk patients
➢ The prevalence of coronary artery disease (CAD) in patients with severe aortic stenosis (AS) is high ➢ in the most recent randomized trials
comparing TAVR to surgery in intermediate-risk patients, >60% have coexisting CAD
TAVR and CAD
The ACTIVATION trial is currently randomizing patients with CAD and severe AS to either pre-TAVR PCI or no pre-TAVR PCI
➢As TAVR indication expands to lower-risk patients who have better long-term prognoses, there will be an increasing need for repeat coronary angiography and percutaneous coronary intervention (PCI) due to progressive CAD and development of acute coronary syndrome
➢However, management of symptomatic CAD after TAVR has not been systematically examined
Coronary Interventions post - TAVR
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CORONARY ACCESS AFTER TAVI
PREVALENCE OF CAD IN TAVR PATIENTS
TAVR Patients with CAD1
40 – 75%
Post-TAVR PCI Rates2,3
3.5 – 5.7%
Median Time to Post-TAVR PCI3
17.7 Months
1.Yudi, et. Al. JACC, 2018.2.Blumenstein et al. Clinical Research in Cardiology, 2015.
3.Allali, et al. Cardiovascular Revasc Med, 2016.
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CORONARY ACCESS AFTER TAVR
Clinical data show that coronary access post-TAVR is technically feasible and highly successful for all valve types
Source TAVIs IncludedAngiography Success Rate
PCI Success Rate
Chetcuti et al., JACC, 2016 169 CoreValve 186/190 (97.9%) 103/113 (91.2%)
Htun et al., Catheter Cardiovasc Inter, 2018 28 CoreValve 71/75 (94.6%) 29/29 (100%)
Zivelonghi et al., Am J Cardiol, 2017 41 Sapien 325 Evolut R
65/66 (98.0%) 17/17 (100%)
Blumenstein et al., Clin Res Cardiol, 2015 19 Sapien 3
10 CoreValve4 Symetis1 Portico1 Jena Valve
34/34 (97.1%) 10/10 (100%)
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CORONARY ACCESS AFTER TAVR
POTENTIAL CHALLENGES TO POST-TAVR CORONARY ACCESS
All commercial trans-catheter aortic valve frames may extend above left coronary ostia in up to 25% patients.1
29 mm Evolut R TAV▪ Annulus Range = 23-26mm
▪ Depth = 3-5mm
26 mm Sapien™* 3 TAV▪ Annulus Range = 23.4-26.4 mm
▪ Depth = 10% of height
25 mm Lotus™* TAV▪ Annulus Range = 23-25mm
▪ Depth = 3.6 mm
Basal plane
20.1 mm
Min 10.4mm
Median 18.4 mm15.9 mm
Max 26.2mm
45.6 mm19 mm
22.5 mm
1.Coronary ostia height measurements are from CoreValve US IDE Trial; Measurements represent the height from the basal plane to the center of the left coronary ostium
IQ Range
To optimize future coronary re-access, implantation depth is critical, especially if the ostia is <10 mm
Because the skirt height of the Evolut-PRO is 13 mm, we need to implant at least 4 mm below the annular plane to ensure the skirt is not overlaying the coronary artery
In this optimal position, it is feasible to engage the coronary artery in a coaxial manner, assuming the native aortic valve leaflets will not interfere with the path to the coronary ostium
If the valve is deployed high, coronary obstruction would not occur due to the narrow waist of the valve and sufficient sinus of Valsalva width
Selective coronary angiography would be difficult in this scenario and would have to occur from a diamond above the ostium, given that the supra-annular valve and its covered segment (e.g., sealing skirt) would be above the level of the ostium
➢ Post-TAVR multidetector computed tomography (CT) can be helpful to determine the anatomy and approach to coronary re-access
➢However, there are several limitations in using this technique ✓ CT cannot be performed in urgent situations✓ it can be a logistical challenge to schedule a CT before an
elective catheterization, especially in terms of the intravenous contrast medium load in patients with renal insufficiency
✓ motion artifact and image quality may limit the ability to visualize leaflet orientation of the transcatheter valve
CT for Coronary Interventions post - TAVR
CT Analysis Post TAVR
CT analysis showed the relationship between skirt height and the coronary ostia, as well as the position of the commissural posts1. the commissural posts were away from the coronary
ostia2. the skirt (13 mm) was well below the left main
coronary artery (23.4 mm from base of the valve)
POST-TAVR CORONARY ACCESSMATERIAL LIST IN CATH LAB
➢J-Tip guidewire
➢Selection of PCI wires
➢Selection of guide catheters
✓Judkins (L & R)
✓Amplatz (L&R), MP, Pigtail, Ikari (R) 1.0/1.5
➢Guide extensions
✓Teleflex GuideLiner™
✓Boston Scientific Guidezilla™
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POST-TAVR CORONARY ACCESSSTEP 1: IDENTIFY CORONARY ORIGINE
▪Identify the coronary take-off points using aortography and a diagnostic pigtail catheter in the outflow portion of frame
▪Identify the frame cells adjacent to the coronary ostia to target when attempting to cannulate the coronaries
▪Recall that the target access zone is located from the waist to node three*
*Assumes implant depth of 3-5mm≈13mm sealing
skirt
Recommended Access Zone
CoreValve Evolut RValves are not shown to scale
20
Post-TAVI Coronary Access | Medtronic
POST-TAVR CORONARY ACCESSSTEP 2: CANNULATE CORONARY OSTIUM
▪Start with a guide catheter, such as a Judkins or an EBU
▪because the frame waist is narrower than the aorta, consider downsizing guide catheter by 0.5 mm
▪Facilitated by using J-wire or angled stiff glide wire to enter the ostia
▪Target the middle of the frame cell co-axial to the take off
▪if difficulty to directly coaxial to the ostium, use another cell
▪Avoid cannulation of the ostia from below the coronary take-off
Coronary Angiography after TAVR
Cannulate left coronary ostium through the middle of valve frame cell at the level of the coronary take-off
Coronary Angiography after TAVR
Cannulate right coronary ostium with a JR 4 catheter
If coronary engagement is unsuccessful try with
✓a non selective placement then engaging with the coronary guidewire
Coronary Interventions post – TAVRStep 2: Unsuccessful Cannulation of Coronary Ostia
Coronary Interventions post – TAVRStep 2: Unsuccessful Cannulation of Coronary Ostia
If coronary engagement is unsuccessful try with✓another guide catheter size
✓an extension catheter when
extra support is needed
or when the distance between
the frame and the coronary
ostia is large
Post-TAVI Coronary AccessStep 3: Perform Intervention
Advance a coronary balloon or stent through the guide catheter to treat the lesion or obstruction
Fluoro image courtesy of F . Ribichini, MD
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POST-TAVR CORONARY ACCESS
STEP 4: CONFIRM PATENCY AND REMOVE CATHETER AND GUIDEWIRE
After performing intervention, confirm patency and disengage guide catheter from ostium and withdraw through frame cell
▪Always remove guide catheter over a wire
▪If there is difficulty removing the guide catheter from ostium, use a balloon to disengage prior to pulling
SAPIEN XT SAPIEN 3
➢The Sapien 3 valve is more likely to extend above the coronary ostia and potentially interfere with coronary access
➢It is well documented that acute coronary obstruction is moreprevalent with balloon-expandable valves
➢Because it does not have a narrowed waist like the self-expanding valve, can extend beyond the STJ, making future coronary access from above the valve more challenging
➢Significant issues with coronary access post-TAVR have not been documented
Balloon Expandable Valve and Coronary Access
Coronary Angiography after Balloon Expandable TAVR
Functional Assessment after Balloon Expandable TAVR
➢Coronary angiography and PCI in post TAVR patients has a high success with both self-expandable and balloon expandable aortic valve devices
➢ Intricate knowledge of the valve design and its relationship with the coronary ostia, sinus of Valsalva, and STJ anatomies can help predict the difficulty in coronary re-access and identify a strategy to manage these patients
Conclusions