Predicting Coronary Occlusion Risk during Redo‐TAVR at First TAVR: Asymmetric Calcification Causes Failure

ABSTRACT Background and Aims Predicting coronary artery occlusion due to sinus sequestration (SS) during a second transcatheter aortic valve (TAV) procedure using pre‐procedural computed tomography (CT) after the first TAV replacement (TAVR) is underreported. This study aimed to investigate the accuracy of SS risk prediction using pre‐procedural CT by comparing it to the actual SS risk observed on post‐procedural CT during TAV‐in‐TAV. Methods and Results We retrospectively evaluated 139 consecutive patients who underwent TAVR with a balloon‐expandable valve. The predicted valve‐to‐sinotubular junction (VTSTJ) length and calcium volume of each coronary cusp were measured on pre‐procedural CT. The observed VTSTJ length was assessed on post‐procedural CT. High SS risk was defined as VTSTJ < 2.0 mm in either the right or left coronary cusp. Pre‐procedural CT classified 78 patients into the high predicted SS (PSS) risk group; 77 (98.7%) showed a high observed SS (OSS) risk on post‐procedural CT. Among the 61 patients classified as having low PSS risk, 44 (72.1%) were found to have high OSS risk post‐TAVR. In this subgroup, patients with high OSS risk had a significantly higher proportion of non‐coronary cusp calcium volume (NCC‐CV) compared to those with low OSS risk (median 48.7% interquartile range (IQR): 42.1–55.2 vs. 39.2% IQR: 33.7–45.4; p = 0.004). Multivariable logistic regression revealed NCC‐CV ≥ 41.6% as an independent predictor of high OSS risk during TAV‐in‐TAV (odds ratio: 12.59 95% confidence interval: 4.20–44.14, p < 0.001). Conclusion Asymmetric NCC calcification was associated with discrepancies in SS predictions on pre‐procedural CT.