Future Coronary Access for Redo Transcatheter Aortic Valve Replacement

A study published in JACC: Cardiovascular Interventions found that differing redo transcatheter aortic valve replacement (TAVR) combinations do not result in equivalent future coronary access.

Geometric characteristics of transcatheter heart valve (THV) design combinations following Sapien XT, Sapien 3, CoreValve Evolut R, ACURATE neo, or Portico TAVR and redo TAVR were compared.

For index TAVR, valves were sized 23, 26, or 29 mm except the ACURATE THV, which were sized small, medium, and large. For the smallest valves, neoskirt heights ranged from 7.2 mm (Sapien XT) to 13.6 mm (Evolut R) and for the largest valves, heights ranged from 10.9 mm (Portico) to 15.5 mm (ACURATE).

The area of lowest accessible cell is smallest for the Evolut R system (range, 15.7-19.6 mm²) and largest for the ACURATE system (range, 489.0-610.0 mm²). Similar trends are observed for the largest fitting circle diameter.

For cell width, the sizes range from 4.3 mm (Evolut R 23 or 29 mm) to 22.4 mm (ACURATE large) and cell height from 6.4 mm (Evolut R 26 mm) to 39.9 mm (ACURATE large).

At redo TAVR, neoskirt height is higher compared with index configuration.

For failed Sapien XT implants, neoskirt heights range between 15.2 to 23.2 mm. The lowest value is observed from 25 mm Portico implanted at -4 mm into a 23 mm Sapien XT compared with the highest which is from 29 mm Evolut R implanted at +4 mm into a 26 mm Sapien XT.

For failed Evolut R, the lowest neoskirt height (22.4 mm) is from a 23 mm Evolut Pro implanted at 0 mm into a 23 mm Evolut R and the highest (31.6 mm) is from a 26 mm Evolut Pro implanted at +4 mm into a 26 mm Evolut R.

Overall, the area of lowest accessible cell is 4.8 mm² observed for a 26 mm Evolut R implanted in a 26 mm Evolut R at +4 mm, which is also associated with the smallest fitting circle diameter (1.9 mm).

Cell misalignment reduces accessibility even further but without effecting the neoskirt height. As an example, the lowest accessible cell dimension for a 26 mm Evolut Pro in Evolut R combination was 15.7 mm² for index, 8.3 mm² for aligned redo, and 5.5 mm² for misaligned redo.

This study is limited, as not all THV designs and combinations could be evaluated.

“This study suggests that most THV designs, and implantation depths result in geometrical interaction that would allow potential selective catheterization following redo TAVR,” the study authors wrote. “However, some of these interactions might significantly impact cell size, and certain THV designs, or implantation positions may be more desirable than others when performing redo TAVR. Finally, cell misalignment can further compromise future coronary access in the context of Evolut in Evolut redo TAVR.”

Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.

Reference

Meier D, Akodad M, Landes U, et al. Coronary access following redo TAVR: impact of THV design, implant technique and cell misalignment. JACC Cardiovasc Interv. Published online July 13, 2022. doi:10.1016/j.jcin.2022.05.005