Incidence, predictors, and clinical outcomes of coronary obstruction following transcatheter aortic valve replacement for degenerative bioprosthetic surgical valves: insights from the VIVID registry

Aims There are limited data on coronary obstruction following transcatheter valve-in-valve (ViV) implantation inside failed aortic bioprostheses. The objectives of this study were to determine the incidence, predictors, and clinical outcomes of coronary obstruction in transcatheter ViV procedures. Methods and results A total of 1612 aortic procedures from the Valve-in-Valve International Data (VIVID) Registry were evaluated. Data were subject to centralized blinded corelab computed tomography (CT) analysis in a subset of patients. The virtual transcatheter valve to coronary ostium distance (VTC) was determined. A total of 37 patients (2.3%) had clinically evident coronary obstruction. Baseline clinical characteristics in the coronary obstruction patients were similar to controls. Coronary obstruction was more common in stented bioprostheses with externally mounted leaflets or stentless bioprostheses than in stented with internally mounted leaflets bioprostheses (6.1% vs. 3.7% vs. 0.8%, respectively; P < 0.001). CT measurements were obtained in 20 (54%) and 90 (5.4%) of patients with and without coronary obstruction, respectively. VTC distance was shorter in coronary obstruction patients in relation to controls (3.24 ± 2.22 vs. 6.30 ± 2.34, respectively; P < 0.001). Using multivariable analysis, the use of a stentless or stented bioprosthesis with externally mounted leaflets [odds ratio (OR): 7.67; 95% confidence interval (CI): 3.14-18.7; P < 0.001] associated with coronary obstruction for the global population. In a second model with CT data, a shorter VTC distance predicted this complication (OR: 0.22 per 1 mm increase; 95% CI: 0.09-0.51; P < 0.001), with an optimal cut-off level of 4 mm (area under the curve: 0.943; P < 0.001). Coronary obstruction was associated with a high 30-day mortality (52.9% vs. 3.9% in the controls, respectively; P < 0.001). Conclusion Coronary obstruction following aortic ViV procedures is a life-threatening complication that occurred more frequently in patients with prior stentless or stented bioprostheses with externally mounted leaflets and in those with a short VTC.

[1]  M. Scharfschwerdt,et al.  Does Undersizing of Transcatheter Aortic Valve Bioprostheses during Valve-in-Valve Implantation Avoid Coronary Obstruction? An In Vitro Study , 2016, The Thoracic and Cardiovascular Surgeon.

[2]  J. Leipsic,et al.  Computed tomography assessment for transcatheter aortic valve in valve implantation: The vancouver approach to predict anatomical risk for coronary obstruction and other considerations. , 2016, Journal of cardiovascular computed tomography.

[3]  K. Takagi,et al.  Impact of preparatory coronary protection in patients at high anatomical risk of acute coronary obstruction during transcatheter aortic valve implantation. , 2016, International journal of cardiology.

[4]  J. Leipsic,et al.  Coronary Obstruction in Transcatheter Aortic Valve-in-Valve Implantation: Preprocedural Evaluation, Device Selection, Protection, and Treatment , 2015, Circulation. Cardiovascular interventions.

[5]  M. Pasic,et al.  Transcatheter aortic valve implantation in failed bioprosthetic surgical valves. , 2014, JAMA.

[6]  Jonathon,et al.  Predictive factors, management, and clinical outcomes of coronary obstruction following transcatheter aortic valve implantation: insights from a large multicenter registry. , 2013, Journal of the American College of Cardiology.

[7]  H. Jilaihawi,et al.  Pre‐emptive positioning of a coronary stent in the left anterior descending artery for left main protection: A prerequisite for transcatheter aortic valve‐in‐valve implantation for failing stentless bioprostheses? , 2013, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[8]  L. Nombela‐Franco,et al.  Coronary obstruction following transcatheter aortic valve implantation: a systematic review. , 2013, JACC. Cardiovascular interventions.

[9]  Christoph Huber,et al.  Aortic root dimensions among patients with severe aortic stenosis undergoing transcatheter aortic valve replacement. , 2013, JACC. Cardiovascular interventions.

[10]  O. Alfieri,et al.  [Guidelines on the management of valvular heart disease (version 2012). The Joint Task Force on the Management of Valvular Heart Disease of the European Society of Cardiology (ESC) and the European Association for Cardio-Thoracic Surgery (EACTS)]. , 2013, Giornale italiano di cardiologia.

[11]  S. Schoenberg,et al.  Aortoiliac CT angiography for planning transcutaneous aortic valve implantation: aortic root anatomy and frequency of clinically significant incidental findings. , 2012, AJR. American journal of roentgenology.

[12]  M. Mack,et al.  Updated standardized endpoint definitions for transcatheter aortic valve implantation: the Valve Academic Research Consortium-2 consensus document. , 2012, Journal of the American College of Cardiology.

[13]  O. Alfieri,et al.  Guidelines on the management of valvular heart disease (version 2012). , 2012, European heart journal.

[14]  C. Hengstenberg,et al.  Transcatheter Aortic Valve Replacement for Degenerative Bioprosthetic Surgical Valves: Results From the Global Valve-in-Valve Registry , 2012, Circulation.

[15]  M. Mack.  Coronary obstruction following transcatheter aortic valve‐in‐valve implantation for failed surgical bioprostheses , 2011, Catheterization and cardiovascular interventions : official journal of the Society for Cardiac Angiography & Interventions.

[16]  Fabien Hyafil,et al.  Multimodal assessment of the aortic annulus diameter: implications for transcatheter aortic valve implantation. , 2010, Journal of the American College of Cardiology.

[17]  Bijoy K Khandheria,et al.  Recommendations for evaluation of prosthetic valves with echocardiography and doppler ultrasound: a report From the American Society of Echocardiography's Guidelines and Standards Committee and the Task Force on Prosthetic Valves, developed in conjunction with the American College of Cardiology Card , 2009, Journal of the American Society of Echocardiography : official publication of the American Society of Echocardiography.

[18]  Paul Schoenhagen,et al.  Aortic root morphology in patients undergoing percutaneous aortic valve replacement: evidence of aortic root remodeling. , 2009, The Journal of thoracic and cardiovascular surgery.

[19]  Jeroen J. Bax,et al.  Noninvasive evaluation of the aortic root with multislice computed tomography implications for transcatheter aortic valve replacement. , 2008, JACC. Cardiovascular imaging.

[20]  C. Duran,et al.  Coronary flow obstruction in percutaneous aortic valve replacement. An in vitro study. , 2007, European journal of cardio-thoracic surgery : official journal of the European Association for Cardio-thoracic Surgery.

[21]  M. Cheitlin.  Percutaneous Aortic Valve Implantation Retrograde From the Femoral Artery , 2007 .

[22]  J M Hasenkam,et al.  Transluminal implantation of artificial heart valves. Description of a new expandable aortic valve and initial results with implantation by catheter technique in closed chest pigs. , 1992, European heart journal.