Key result
Left main protection during TAVR yields 0% major cardiovascular events or coronary obstruction regardless of stent placement.
Why the study?
The routine use of left main protection with or without stent placement during TAVR in high-risk patients remains controversial and requires evaluation of outcomes and anatomic predictors.
What are the outcomes and anatomic predictors of left main stenting during TAVR with left main protection?
Cohort (n=1,925)
No
What are the outcomes and anatomic predictors of left main stenting during TAVR with left main protection?
Left main protection during TAVR is safe and effective, with specific anatomic factors such as annular circumference and sinotubular junction ratio predicting the need for stent deployment.
Answers are grounded in this paper and cite their sources.
Supports selective left main protection during TAVR; hypothesis-generating and requires randomized trials before practice change.
Background Coronary obstruction during transcatheter aortic valve replacement (TAVR) is a rare, yet life-threatening, complication. The routine use of left main (LM) protection with or without stent placement in high-risk patients remains controversial. The aim of this study was to evaluate the outcomes of LM protection during TAVR and identify anatomic factors associated with need for stent placement. Methods We retrospectively reviewed all TAVR cases (native and valve-in-valve) performed in our institution between 2014 and 2019 and identified patients who underwent LM protection with a coronary wire, balloon, and/or stent during the procedure. We compared the pre-TAVR computed tomography aortic root characteristics, procedural data, short-, and long-term outcomes among the patients who eventually received an LM stent and those who did not. Results Among 1925 TAVR patients, 41 (2.1%) underwent LM protection, and 10 of them (25%) had eventually a stent placed in the LM for threatened obstruction after valve deployment. In the native TAVR group ( n = 35), 8 patients underwent LM stenting. A larger TAVR prosthesis, larger annular circumference (83.8 vs 76.1 mm; P = .038), lower ratio of sinotubular junction diameter to prosthesis size (1.02 vs 1.11; P = .032), and longer left coronary cusp (15.1 vs 13.9 mm; P = .18) were associated with higher incidence of LM stenting. In the valve-in-valve TAVR group ( n = 6), 5 patients had a valve-to-coronary distance of less than 4 mm, and 2 of them received an LM stent. Both stent and nonstent groups had excellent outcomes with no major adverse cardiovascular events or coronary obstruction at 30 days. After a median follow-up of 351 days, 4 patients died (9.7%) (1 in the stent and 3 in the nonstent group), without any cases of late coronary obstruction or percutaneous coronary intervention in either group. Conclusions LM protection with a coronary guidewire, balloon, or stent is a safe and effective method of coronary protection during TAVR in appropriately selected high-risk patients. Annular circumference, prosthesis size, left coronary cusp length, LM ostial height, and ratio of sinotubular junction to prosthesis size are important predictors of stent deployment.
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Hsiung et al. (2022) conducted a cohort in Transcatheter aortic valve replacement (n=1,925). Left main stent placement vs. Left main protection without stent placement was evaluated on Major adverse cardiovascular events or coronary obstruction at 30 days. Left main protection during TAVR resulted in 25% of patients needing a stent, with 0% major adverse cardiovascular events or coronary obstruction at 30 days in both stent and nonstent groups.
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