Valve-in-Valve Challenges: How to Avoid Coronary Obstruction

Q: What is the clinical evidence from this study?

Study design: Review. Population: Failed surgical bioprosthesis requiring transcatheter aortic valve replacement. Intervention: Transcatheter aortic valve-in-valve (VIV) replacement vs. TAVR in native aortic valve. Primary outcome: Coronary obstruction.

Fernando Luiz de Melo Bernardi; Danny Dvir; Josep Rodés‐Cabau; Henrique Barbosa Ribeiro

doi:10.3389/fcvm.2019.00120

August 23, 2019Frontiers in Cardiovascular MedicineOpen Access

Valve-in-Valve Challenges: How to Avoid Coronary Obstruction

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Key result

Aortic valve-in-valve procedures for failed surgical bioprostheses are associated with an approximately 4- to 6-fold higher risk of coronary obstruction compared to TAVR in native aortic valves.

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Why the study?

Aortic valve-in-valve procedures carry an elevated risk of life-threatening coronary obstruction, but studies on preemptive protective strategies are lacking.

Key Points

To review the mechanisms, anatomical risk features, and preventive strategies for coronary obstruction during transcatheter aortic valve-in-valve procedures.
Clinical review examining pathophysiological mechanisms, anatomical risk predictors, and preemptive interventional strategies for avoiding coronary obstruction in aortic valve-in-valve interventions.
Coronary obstruction carries an approximately 6-fold higher risk in valve-in-valve procedures compared to native TAVR, with up to one-third of events presenting in a delayed fashion and presenting with severe hypotension and high mortality.
High-risk anatomical features identified by pre-procedural multi-slice computed tomography include low coronary ostial height, shallow sinuses of Valsalva, short virtual transcatheter valve-to-coronary ostial distance, and specific surgical bioprosthesis designs.
Preemptive protective strategies, including coronary guidewire placement with or without an undeployed safety stent, offer potential risk mitigation in anatomically vulnerable cases.

Structured PICO

P

Population

A review of patients undergoing transcatheter aortic valve-in-valve procedures for failed surgical bioprostheses, focusing on the risk factors and management of coronary obstruction.

I

Intervention

Pre-procedural multi-slice computed tomography (MSCT) planning and preemptive protective strategies (e.g., coronary wiring, chimney stenting, BASILICA).

Pre-procedural MSCT is crucial for identifying high-risk features for coronary obstruction during TAVR valve-in-valve procedures, allowing for preemptive protective strategies like chimney stenting or BASILICA.

Limitations

Lack of studies evaluating preemptive protective strategies with coronary wiring in high-risk patients
Limited current evidence for valve-in-valve procedures in failed TAVR bioprostheses
Lack of studies evaluating preemptive protective strategies

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Implication

Elevated coronary obstruction risk in VIV TAVR warrants preprocedural CT planning; leaves open optimal mitigation strategies.

Abstract

Coronary obstruction is a rare but life-threatening complication in patients undergoing transcatheter aortic valve replacement (TAVR). Aortic valve-in-valve (VIV) procedures to treat failed surgical bioprosthesis is associated with ~6-fold higher risk for coronary obstruction in certain situations. The primary mechanism consists in the occlusion of the coronary ostium by the dislodged leaflet from the bioprosthesis after deployment of the transcatheter heart valve (THV), which most commonly occurs during the index procedure, but in up to 1/3 of cases a delayed presentation ensues. The clinical presentation consists of severe hypotension and ECG changes in most of the patients, with very high mortality rates. Therefore, pre-procedural multi-slice computed tomography is crucial for identifying high-risk features, such as low coronary heights, shallow sinuses of Valsalva, and short virtual THV to coronary ostial distance (VTC). Also, some models of surgical bioprosthesis present an increased risk for this dreadful complication. Preemptive protective strategies with coronary wiring, with or without placement of an undeployed stent, could mitigate the risks associated with this complication in high-risk patients, even though studies are lacking. This review aims to take a clinical perspective on the challenges in avoiding this complication during VIV procedures.

Discussion

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Cite This Study

Bernardi et al. (2019) conducted a review in Failed surgical bioprosthesis requiring transcatheter aortic valve replacement. Transcatheter aortic valve-in-valve (VIV) replacement vs. TAVR in native aortic valve was evaluated on Coronary obstruction. Aortic valve-in-valve procedures for failed surgical bioprostheses are associated with an approximately 4- to 6-fold higher risk of coronary obstruction compared to TAVR in native aortic valves.

synapsesocial.com/papers/6a7a5752b008f0cadf325ed6 https://doi.org/10.3389/fcvm.2019.00120

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Valve-in-Valve Challenges: How to Avoid Coronary Obstruction

Figures

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

Valve-in-Valve Challenges: How to Avoid Coronary Obstruction

Figures

Key Points

Structured PICO

Limitations

Ask about this paper

Implication

Abstract

Discussion

Cite This Study

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