Coronary Obstruction After Transcatheter Aortic Valve Replacement: From Risk Prediction to Prevention

Transcatheter Aortic Valve Replacement in Patients at High Risk of Coronary ObstructionJournal the Society for Cardiovascular Angiography & InterventionsVol. 1Issue 4100347PreviewCoronary obstruction following transcatheter aortic valve replacement (TAVR) is a life-threatening complication. For patients elevated risk, it not known how choice influenced by clinical and anatomic factors outcomes differ between platforms. high risk coronary obstruction, we sought to describe anatomical characteristics treated with both balloon-expandable (BE) self-expanding (SE) valves. Full-Text PDF Open AccessLeft Main Protection During With Balloon-Expandable ValveJournal 4100339PreviewCoronary during rare, yet life-threatening, The routine use left main (LM) protection or without stent placement high-risk remains controversial. aim this study was evaluate LM TAVR identify associated need placement. Access an often fatal but fortunately rare complication (TAVR),1Ribeiro H.B. Webb J.G. Makkar R.R. et al.Predictive factors, management, implantation: insights from large multicenter registry.J Am Coll Cardiol. 2013; 62: 1552-1562Crossref PubMed Scopus (362) Google Scholar,2Ribeiro Nombela-Franco L. Urena M. al.Coronary systematic review.JACC Cardiovasc Interv. 6: 452-461Crossref (181) Scholar observed <1% native procedures 2.5%-3.5% valve-in-valve (VIV) cases.3Dvir D. Leipsic J. Blanke P. preprocedural evaluation, device selection, protection, treatment.Circ 2015; 8e002079Crossref (139) previously described include (female sex), procedural (larger sizes, VIV procedure), variables including low ostia, shallow sinuses Valsalva (SOV) sinotubular junction, elongated leaflets, presence bulky calcified nodules, as well projected distances virtual implant ostium, Valsalva, junction.1Ribeiro Scholar, 2Ribeiro 3Dvir 4Lederman R.J. Babaliaros V.C. Rogers T. al.Preventing replacement: computed tomography BASILICA.JACC 2019; 12: 1197-1216Crossref (67) 5Khan J.M. Greenbaum A.B. al.The BASILICA trial: prospective investigation intentional leaflet laceration prevent obstruction.JACC 1240-1241Crossref (116) As patent bypass graft may protect adverse consequences individualized decisions regarding must take into account interplay multiple elements are best informed detailed angiographic assessment (CTA) aorto-coronary-valvular complex. Given predictive capability CTA its consequent dismal prognosis, preventive interventional strategies have been developed that (placement wire, balloon, and/or stent) modification (Bioprosthetic Scallop Intentional Laceration Iatrogenic Artery [BASILICA]) (Figure 1).4Lederman In current issue JSCAI, 2 manuscripts draw focus on TAVR. First, analysis 1925 consecutive done Cleveland Clinic shows artery guidewire, attempted 2% (using valves) only 10 41 total protected (25%) required threatened obstruction.6Hsiung I. Spilias N. Bazarbashi al.Left valve.J Soc Angiogr 2022; 1100339Google predictors implantation were consistent prior reports exception half who received stents had surgery. Clinical through 1 ​year favorable similar regardless implantation. Second, 19-center registry deemed “high risk” categorized pre-emptive presented Ahmed al,7Ahmad Y. Oakley Yoon S. al.Transcatheter versus balloon expandable valves obstruction.J 1: 100347Google 3 ​years stratified type implanted (self-expanding [SEV] vs valve). Mortality increased SEV ascribed rate occlusion; however, significant differences baseline (known occlusion) types preclude definitive comparisons being made. From these reports, now consider important, novel observations made, limitations analyses, unanswered questions remain. analyses reports. studies retrospective, observational small subgroups defined perceived TAVR; criteria using neither prospectively nor uniformly applied (protocolized) obscured influence “operator discretion judgment.” No independent imaging core laboratory events committee identified either study, leaving potential site-determined bias exist. Further, (wire, (SEV valve) randomly assigned. This concern reflected predict occlusion deployed, which confounds comparison follow-up (rates occlusion, mortality). fact SEVs used predominantly cases likely reflects attempt mitigate patient-prosthesis mismatch supra-annular design desire maintain recapturability should occur deployment. Irrespective motivations one over other, no firm recommendations can be drawn study. Both reflect continued define more consistently select strategies. Finally, addition CT information would invaluable interpreting differentiate selected those not. example, what prevalence among 1884 incidence population? Similarly, “denominator” group 236 registry? What larger implanted? population enough allow propensity score matching inverse probability treatment weighting statistical techniques adjust confounding Indeed, very valuable obtained groups included analysis. Lastly, many procedure referred surgery why? patients? Technological enhancements technology reduced complications paravalvular regurgitation, vascular complications, pacemaker requirement. Novel development lower profiles, sinus cutouts, anchor rings/locators grasp restrain native/bioprosthetic leaflets. Device will soon enable precise commissural alignment deployment facilitate access stenting needed. Whether technologies favorably impact likelihood determined. simplified removal expand utility technique further reduce due Rigorous low-frequency events, such TAVR, challenging, “gold standard” formulating plans guidelines (ie, large-scale randomized trials) feasible lack power, inability randomize, other considerations. Multicenter collaborations, Ahmad al, inform practice when sources minimized. subject treat become increasingly important coming decade structural degeneration involving occurs ensuing perform accelerates. Prospective registries laboratories event adjudication play role helping optimal algorithms prediction, prevention, Dr Garcia consultant Medtronic, Edwards Lifesciences, Abbott Vascular; institutional research grants Lifesciences , Vascular Gore Boston Scientific ; proctor Lifesciences; supported Harold C. Schott Foundation Endowed Chair Structural Valvular Heart Disease. Kereiakes reported financial interests.