Percutaneous Coronary Intervention in Transcatheter Aortic Valve Implantation Patients: Overview and Practical Management

Figure 1. Unsuccessful PCI after TAVI. In this elderly patient, the heart team's decision was to perform TAVI without prior coronary revascularization due to high age and unfavorable morphology. Following TAVI with an ACURATE neo™ THV, the patient developed cardiogenic shock due to a combination of relevant paravalvular leakage [red arrows in (A)] and presumably untreated coronary artery disease (B). We performed emergent post-dilatation to reduce paravalvular leakage and subsequently carried out coronary intervention of the LAD (C) with the implantation of a drug-eluting stent. Thereafter, there was no reflow in the distal LAD (D), and consequently, the patient deceased during the procedure. PCI, percutaneous coronary intervention; TAVI, transcatheter aortic valve implantation; THV, transcatheter heart valve; LAD, left anterior descending artery.

Figure 2. Unsuccessful PCI prior to TAVI. (A) Coronary angiography of the left coronary artery with severe tandem stenoses (red arrows) of the LAD in a patient scheduled for TAVI. The decision was made for ad hoc PCI. After balloon dilatation, a drug-eluting stent was implanted in the mid-LAD (B). Thereafter, no reflow in the distal LAD was noted (C), and the patient was hemodynamically compromised with the need for cardiopulmonary rescuscitation and emergent balloon valvuloplasty of the aortic stenosis (D). Due to persistent low output and residual high transaortic gradients, the decision was made to perform emergent TAVI using a SAPIEN 3 balloon-expandable device (E). Despite successful TAVI, the patient deceased in the course of multiorgan failure. PCI, percutaneous coronary intervention; TAVI, transcatheter aortic valve implantation; LAD, left anterior descending artery.

Figure 3. Coronary engagement in different transcatheter heart valves. (A) Unselective engagement of the left coronary artery (LCA) using a JL4 diagnostic catheter after TAVI with an Evolut R prosthesis. (B) Semi-selective engagement of the LCA using an extra backup catheter (EBU 3.75) in a patient with prior Portico valve. (C) Selective, but transprothetic engagement of the LCA with a JL4 catheter following TAVI with a SAPIEN 3 device. (D) Unselective catheterization of the right coronary artery (RCA) with a JR4 guiding catheter after TAVI with a Portico device. (E) Selective and supra-valvular engagement of a diagnostic JL4 catheter in a patient with prior ACURATE neo™ valve. (F) Ostial engagement of the RCA in a patient with prior SAPIEN 3 valve. LCA, left coronary artery, JL, Judkins Left, TAVI, transcatheter aortic valve implantation; EBU, extra backup, RCA, right coronary artery.

Figure 4. Differences in frame height and cell dimensions between SAPIEN XTTM and SAPIEN 3TM/SAPIEN 3 UltraTM. Compared with SAPIEN XT, the frame height (A,B) of SAPIEN 3TM and SAPIEN 3 UltraTM is taller, potentially leading to more interference with the coronary ostia, but the cells in the upper row are bigger thereby facilitating coronary access (red asterisk). The newer SAPIEN 3 UltraTM retains the SAPIEN 3TM stent frame design, but its outer skirt is 40% higher to provide a better sealing (C). Image courtesy of Edwards Lifescience Corporation.

Figure 5. Dimensions of the frame, skirt, and commissural post heights of the CoreValve Evolut-ProTM. With a frame height of 45 mm, the CoreValve Evolut-ProTM inevitably exceeds the coronary ostia. Due to the “waist” of the stent frame, enough space between the coronary ostia and the valve is provided. With kind approval by Medtronic (Dublin, Ireland).

Figure 6. Schematic presentation of different positions of the coronary ostia in relation to the skirt and the commissural posts in CoreValve Evolut-ProTM. The black dots represent two examples of positionings of the coronary ostia. The green line depicts the annular plane, the blue line represents the upper limit of the sealing skirt, and the red line marks the course of the skirt rising up with the commissural post. In scheme (A), the coronary orifices are beyond the skirt and the commissural posts, so that a coaxial intubation is likely to be achieved. In scheme (B), the coronary ostia are in front of the commisural post, so the cannulation must be performed through a diamond adjacent to it. Scheme (C) shows an example of low-lying coronary ostia and low implantation depth, with the sealing skirt facing the coronary ostia. Coronary engagement should be performed from a diamond above.

Figure 7. Selective engagement of the RCA via a guiding catheter extension. In this patient presenting with acute coronary syndrome with the culprit lesion in the mid-section of the RCA (black arrow), proper engagement of the RCA with the guiding catheter JR4 was not possible. Advancing a guiding catheter extension (white arrow; GuidezillaTM, Boston Scientific, Marlborough, Massachusetts, USA) led to successful selective cannulation. RCA, right coronary artery; JR, Judkins Right.

Figure 8. Dimensions of the total height, stent body height, and commissural post height of the ACURATE neoTM. The upper crown of the stent body captures the native leaflets and anchors the device supra-annually. The stabilization arches provide axial self-alignment within the ascending aorta. With kind approval by Boston Scientific (Marlborough, Massachusetts, USA).