Coronary cannulation failures following transcatheter aortic valve replacement (TAVR) were found to be higher in patients receiving Evolut TAVs, according to a study published in the Journal of American College of Cardiology: Cardiovascular Interventions.
In this prospective, registry-based study, 399 patients (median age, 81 years; interquartile range [IQR], 77-85 years) presenting with severe aortic stenosis of the native valve and scheduled to undergo TAVR were enrolled. Patients were assessed with left and right coronary angiography before and after the procedure. TVAR was considered selective when the catheter was completely engaged, semiselective when the catheter was in front of the coronary ostium, and unsuccessful when it was impossible to obtain selective or semiselective engagement.
In this cohort, average transaortic gradient was 46.1±13.4 mmHg and 30-day mortality was predicted to be 3.6±2.2% using the Society of Thoracic Surgeons mortality score.
A total of 41.0% of patients received an Evolut R or Evolut PRO device, 32.0% a SAPIEN 3 or SAPIEN ULTRA device, 24.0% an Acurate neo TF device, and 3.2% a Portico device. Placement was successful in 95.2% of patients.
Cannulation was found to be selective in 12.0% and 31.7% for left and right coronary arteries, respectively. Canulation was more challenging for the right vs left artery (P <.001). The right vs left artery required longer cannulation time (mean, 59 s; IQR, 30-100 s vs mean, 30 s; IQR, 10-80 s, respectively; P <.01) and more contrast dye (mean, 4 mL; IQR, 3-8 mL vs mean, 3 mL; IQR, 0-6 mL, respectively; P <.01).
A total of 7.7% of cannulation attempts were unsuccessful (4.7% left coronary artery and 4.0% right). Among the unsuccessful cannulations, 22 of the 23 had an Evolut R or Evolut PRO device implanted (P <.001). Evolut devices had higher odds of an unsuccessful outcome (odds ratio [OR], 29.6; 95% CI, 2.5-335.0; P <.01).
Patients who had unsuccessful vs successful cannulation had smaller annular areas (3.6±0.5 vs 4.3±0.8 cm2, respectively; P <.01), smaller mean sinus of Valsalva diameters (26.9±2.0 vs 30.7±3.8 mm, respectively; P <.01), and smaller sinotubular junction diameters (24.8±2.1 vs 27.3±3.3 mm, respectively; P <.01) and required higher prosthesis implantation (-5.0±1.2 vs -6.2±3.0 mm, respectively; P <.01), higher mean TAV-sinus of Valsalva diameter relation (-0.7±7.7% vs -13.6±9.3%, respectively; P <.01), and annular area oversizing (37.6±10.6% vs 27.9±12.8%, respectively; P <.01).
After implantation of an Evolut device, cutoffs for unsuccessful procedures were the following: TAV-sinus of Valsalva relation of -0.7% (area under the curve [AUC], 0.70; 95% CI, 0.56-0.83; P <.01) and mean TAV depth of -6 mm (AUC, 0.84; 95% CI, 0.77-0.91; P <.01).
A potential limitation of this study was the choice to not include position of the TAV commissures in relation with the native aortic valve.
These data indicated that cannulization after a TAVR procedure was most likely to be unsuccessful after the implantation of an Evolut device. A greater TAV-sinus of Valsalva relation or high TAV implantation depth exacerbated the failure rate.
Disclosure: Multiple authors declared affiliations with industry. Please refer to the original article for a full list of disclosures.
Barbanti M, Costa G, Picci A, et al. Coronary cannulation after transcatheter aortic valve eeplacement: The RE-ACCESS study. JACC Cardiovasc Interv. 2020;S1936-8798(20)31494-1. doi:10.1016/j.jcin.2020.07.006