Laser ablation for preventing coronary obstruction and maintaining coronary access in redo-TAVR: A proof of concept.

BACKGROUND: Redo-transcatheter aortic valve replacement (TAVR) is a promising treatment for transcatheter aortic valve degeneration, becoming increasingly relevant with an aging population. In redo-TAVR, the leaflets of the initial (index) transcatheter aortic valve (TAV) are displaced vertically when the second TAV is implanted, creating a cylindrical cage that can impair coronary cannulation and flow. Preventing coronary obstruction and maintaining coronary access is essential, especially in young and low-risk patients undergoing TAVR. This study aimed to develop a new leaflet modification strategy using laser ablation to prevent coronary obstruction and facilitate coronary access after repeat TAVR. METHODS: To evaluate the feasibility of the leaflet modification technique using laser ablation, the initial phase of this study involved applying a medical-grade ultraviolet laser for ablation through pericardial tissue. Following this intervention, computational fluid dynamics simulations were utilized to assess the efficacy of the resulting perforations in promoting coronary flow. These simulations played a crucial role in understanding the impact of the modifications on blood flow patterns, ensuring these changes would facilitate the restoration of coronary circulation. RESULTS: Laser ablation of pericardium leaflets was successful, demonstrating the feasibility of creating openings in the TAV leaflets. Flow simulation results show that ablation of index valve leaflets can effectively mitigate the flow obstruction caused by sinus sequestration in redo-TAVR, with the extent of restoration dependent on the number and location of the ablated openings. CONCLUSIONS: Laser ablation could be a viable method for leaflet modification in redo-TAVR, serving as a new tool in interventional procedures.

Transcatheter Aortic Valve Replacement and Coronary Protection Guided by Deep Learning and 3-Dimensional Printing.

OBJECTIVE: In this case report, the auxiliary role of deep learning and 3-dimensional printing technology in the perioperative period was discussed to guide transcatheter aortic valve replacement and coronary stent implantation simultaneously. CASE PRESENTATION: A 68-year-old man had shortness of breath and chest tightness, accompanied by paroxysmal nocturnal dyspnea, 2 weeks before presenting at our hospital. Echocardiography results obtained in the outpatient department showed severe aortic stenosis combined with regurgitation and pleural effusion. The patient was first treated with closed thoracic drainage. After 800 mL of pleural effusion was collected, the patient's symptoms were relieved and he was admitted to the hospital. Preoperative transthoracic echocardiography showed severe bicuspid aortic valve stenosis combined with calcification and aortic regurgitation (mean pressure gradient, 42 mmHg). Preoperative computed tomography results showed a type I bicuspid aortic valve with severe eccentric calcification. The leaflet could be seen from the left coronary artery plane, which indicated an extremely high possibility of coronary obstruction. After preoperative imaging assessment, deep learning and 3-dimensional printing technology were used for evaluation and simulation. Guided transcatheter aortic valve replacement and a coronary stent implant were completed successfully. Postoperative digital subtraction angiography showed that the bioprosthesis and the chimney coronary stent were in ideal positions. Transesophageal echocardiography showed normal morphology without paravalvular regurgitation. CONCLUSION: The perioperative guidance of deep learning and 3-dimensional printing are of great help for surgical strategy formulation in patients with severe bicuspid aortic valve stenosis with calcification and high-risk coronary obstruction.

Transcatheter aortic valve implantation in patients with anomalous origin of a coronary artery.

Transcatheter aortic valve implantation (TAVI) has become a well-established treatment option for elderly patients with symptomatic severe aortic stenosis. Coronary artery anomalies are an infrequent finding and there have only been few anecdotal reports of patients with coronary anomalies treated with TAVI. We here present a comprehensive overview of existing reports in addition to an own case series to facilitate better understanding of this potentially challenging clinical scenario.

Leaflet modification or chimney stenting in patients at risk for coronary artery obstruction in valve-in-valve procedure for a failed surgical bioprosthetic aortic valve.

Valve-in-valve transcatheter aortic valve replacement (VIV-TAVR) for a degenerated surgical aortic bioprosthesis is a well-established treatment modality but carries an increased risk of coronary artery obstruction (CAO) with potentially catastrophic consequences. Both chimney stenting and leaflet modification by BASILICA (Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Obstruction) are increasingly employed and can be highly effective means of preventing CAO. Using a case report, in which both strategies were utilized, as a platform for detailed discussion, we address the indications, contraindications, and relative merits of each technique in the prevention of CAO.

Heart Rate Induced Dynamic Coronary Ischemia Secondary to Aortic Valve Insufficiency from a Diminutive Aortic Valve Leaflet: Diagnosis and Repair.

Hemodynamically significant congenital obstruction of the coronary arteries is a rare phenomenon. The potential etiology of these obstructions is variable including coronary os stenosis, occlusive fibrous webs, or a dysplastic aortic valve leaflet resulting in obstruction. In infants, diagnosis of these coronary lesions is often difficult due to the small anatomic size and limitations of imaging modalities in the setting of the underlying rapid heart rates. We present a case of an infant presenting in heart failure secondary to dynamic coronary artery insufficiency from a diminutive aortic valve leaflet and aortic sinus and variable levels of aortic valve insufficiency based on heart rate.

Optimizing self-expandable transcatheter heart valve sizing in patients with small sinus of Valsalva.

OBJECTIVES: To evaluate the feasibility and efficacy of transcatheter aortic valve replacement (TAVR) in patients with small sinus of Valsalva (SOV). BACKGROUND: Patients with small SOV are considered unfavorable for TAVR since it carries risk of coronary obstruction after valve implantation. Therefore, these patients with small SOV were excluded from previous clinical trials. METHODS: Between February 2017 and February 2019, a total of 139 consecutive patients with severe aortic stenosis (AS) undergoing TAVR were prospectively enrolled in the Tokai Valve Registry. Patients with small SOV who were treated with smaller size of self-expandable transcatheter heart valve (THV) than expected by perimeter-based sizing were included in this study. Eleven patients (7.9%) were included. RESULTS: Mean age was 86.5 ± 3.8 years and median STS Score was 8.5% (interquartile range: 6.3-12.3%). Device success was accomplished in all patients and no coronary obstruction was observed. No moderate/severe paravalvular leakage, new onset conduction disturbance, and new permanent pacemaker implantation were noted. At 30-day follow-up, mean aortic valve gradient was 6.9 ± 1.7 mmHg and mean indexed aortic valve area was 0.95 ± 0.16 cm2 /m2 . Prosthetic valve performance was stable at 12-month follow-up. No severe prosthesis patient mismatch was documented at any time point. No in-hospital, 30-day, and 12-month mortality were observed. The median follow-up was 711 days (IQR: 547-803 days), and no patient was lost to follow-up. CONCLUSIONS: Our preliminary experience suggests favorable safety and efficacy of TAVR utilizing self-expandable THV with intentional down-sizing in patients with severe AS and small SOV in a mid-term follow-up.

Distribution of C-arm projections in native and bioprosthetic aortic valves cusps: Implication for BASILICA procedures.

OBJECTIVES: We sought to document aortic cusps fluoroscopic projections and their distributions using leaflet alignment which is a novel concept to optimize visualization of leaflets and for guiding BASILICA (bioprosthetic or native aortic scallop intentional laceration to prevent coronary artery obstruction) and determine whether these projections were feasible in catheter laboratory. BACKGROUND: Optimal fluoroscopic projections of aortic valve cusps have not been well described. METHODS: A total of 128 pre-transcatheter aortic valve replacement (pre-TAVR) computed tomographies (CT) (72 native valves and 56 bioprosthetic surgical valves) were analyzed. Using CT software (3Mensio, Pie medical imaging, the Netherlands), leaflet alignment was performed and the feasibility of these angles, which were defined as rate of obtainable with efforts (within LAO/RAO of 85° and CRA/CAU of 50°) were evaluated. RESULTS: High feasibility was seen in right coronary cusp (RCC) front view (100%) and left coronary cusp (LCC) side view (99.2%), followed by noncoronary cusp side view (95.3%). In contrast, low feasibility of RCC side view (7.8%) and LCC front view (47.6%) was observed. No statistical differences were seen between the distribution of native valves and bioprosthetic surgical valves. With patient/table tilt of 20°LAO and 10°CRA, the feasibility of RCC side view and LCC front view increased to 43.7 and 85.2%, respectively. CONCLUSION: Distributions of each cusp's leaflet alignment follows "sigmoid curve" which can provide better understanding of aortic valve cusp orientation in TAVR and BASILICA. RCC side view used in right cusp BASILICA is commonly unachievable in catheter laboratory and may improve with patient/table tilt.

Left Ventricular Outflow Tract Gradient Is Associated With Coronary Artery Obstruction in Children With Williams-Beuren Syndrome.

OBJECTIVES: Patients with Williams-Beuren syndrome are associated with a high risk of hemodynamic collapse during sedation and/or anesthesia, presumably due to occult coronary obstruction. The objective of this study was to determine the association between transthoracic echocardiogram findings and the presence of coronary obstruction to examine if coronary obstruction can be predicted by transthoracic echocardiogram before anesthesia. DESIGN: Retrospective data analysis of patients with Williams-Beuren syndrome who underwent transthoracic echocardiogram, cardiac catheterization, and/or surgical interventions to determine the correlation between echocardiogram findings and the presence of coronary obstruction determined by cardiac catheterization and/or surgery. SETTING: Single-center university teaching hospital. PARTICIPANTS: The study included 49 patients with Williams-Beuren syndrome who underwent transthoracic echocardiogram, cardiac catheterization, and/or surgical interventions. MEASUREMENTS AND MAIN RESULTS: The only variable associated with coronary artery obstruction was the maximum instantaneous gradient (MIG) across the left ventricular outflow tract (LVOT) on a transthoracic echocardiogram. LVOT MIG ≥ 75 mmHg as the optimal cutoff value was associated with coronary artery obstruction (area under the curve 0.659, odds ratio 6.71, 95% CI 1.31-34.35, p = 0.022). CONCLUSION: LVOT gradient can serve as a good predictor of the presence of coronary obstruction in patients with Williams-Beuren syndrome.

Transcatheter aortic valve implantation 10 years after valve-in-valve transcatheter aortic valve implantation for failing aortic valve homograft root replacement.

Valve-in-valve transcatheter aortic valve implantation (ViV-TAVI) is an established therapy for a degenerated surgical bioprosthesis. TAVI-in-TAVI following ViV-TAVI has not been previously performed. We report a high-risk patient presenting with severe left ventricular failure secondary to undiagnosed critical aortic stenosis due to degeneration of the implanted transcatheter heart valve more than a decade after initial ViV-TAVI for a failing stentless aortic valve homograft. Successful TAVI-in-TAVI reversed the clinical and echocardiographic changes of decompensated heart failure with no evidence of coronary obstruction.

Delayed Coronary Obstruction after Transcatheter Aortic Valve Replacement - An Uncommon But Serious Complication.

As transcatheter aortic valve replacement (TAVR) becomes the mainstream treatment for valvular aortic stenosis, it is vitally important to recognize its associated procedural complications. Among the clinically relevant but uncommonly seen complications, the development of delayed coronary obstruction (DCO) occurring during the early post-procedural phase or even later following the index TAVR procedure, has been reported. These reports have raised concerns as TAVR comes more common in lower-risk patients. In this review article, we explored the implications of DCO for pre-procedural computed tomography evaluation, valve selection and sizing, intra-procedural manipulation, and approaches to post-procedural management.

[Delayed coronary obstruction of the left main artery after transcatheter aortic valve replacement].

Coronary arteries obstruction associated with transcatheter aortic valve implantation (TAVI) may occur either during the procedure or after it. In the latter coronary obstruction can be further divided into early (7 days after procedure) or delayed one (7 days). Delayed coronary obstruction (DCO) is referred as a rare but devastating complication after TAVI and is associated with the extremely high mortality. This case demonstrates the objective difficulties of timely diagnostics of DCO. Since the results of non-invasive methods are indetermined in most cases, the authors conclude that even low-specific clinical symptoms must be interpreted as the definite rationale for the implementation of invasive diagnostic and treatment strategy.

Incidence and predictors of coronary obstruction following transcatheter aortic valve implantation in the real world.

OBJECTIVES: Coronary obstruction (CO) is a rare but serious complication of transcatheter aortic valve implantation (TAVI). There are very limited data regarding CO following TAVI. The aim of this study was to evaluate the incidence and outcomes of CO after TAVI and identify the predictors including the valve type. METHODS: Between October 2006 and March 2015, 1,203 TAVI cases were performed in our institution. Of them, 814 cases whose coronary height was measured using computed tomography for screening were analyzed in this study. RESULTS: The Edwards SAPIEN/SAPIEN XT (S/XT) was used in 427 (52.4%) cases, the CoreValve in 265 (32.6%), and the S3 in 122 (15.0%). CO occurred in 8 (1.0%) cases, 1.6% with S/XT, 0.4% with CoreValve, and 0% with S3. All instances of CO occurred at the left coronary artery. The 30-day mortality was significantly higher in cases of CO (37.5% vs. 5.8%, P = 0.010). The frequency of CO tended to be lower in recipients of the CoreValve (0.4%) and S3 (0%) compared with the S/XT (1.6%) (P = 0.188 for CoreValve vs. S/XT, P = 0.022 for S3 vs. S/XT). CONCLUSIONS: CO has poor outcomes and identification of patients at risk of CO to take preventive measures is crucial. The preliminary data showing that the occurrence of CO is low in patients receiving the S3 despite increased prosthesis height need further confirmation. © 2017 Wiley Periodicals, Inc.

A case of anomalous left coronary artery obstruction caused by lotus valve implantation.

Trans-catheter aortic valve implantation (TAVI) in patients with high surgical risk is an alternative therapeutic option for severe aortic stenosis. Although second generation TAVI devices are available now, this therapy still cannot overcome all serious complications. Among them, coronary obstruction is a life threatening complication, however, there is no report concerning the complication in patients with anomalous coronary arteries. Here we present a case with coronary obstruction of an anomalous left main coronary that occurred after implantation of the mechanical expanding Lotus valve (Boston Scientific Inc.). © 2016 Wiley Periodicals, Inc.

Aortic Valve-in-Valve Procedures: Challenges and Future Directions.

Aortic valve-in-valve (ViV) procedures are increasingly performed for the treatment of surgical bioprosthetic valve failure in patients at intermediate to high surgical risk. Although ViV procedures offer indisputable benefits in terms of procedural time, in-hospital length of stay, and avoidance of surgical complications, they also present unique challenges. Growing awareness of the technical difficulties and potential threats associated with ViV procedures mandates careful preprocedural planning. This review article offers an overview of the current state-of-the-art ViV procedures, with focus on patient and device selection, procedural planning, potential complications, and long-term outcomes. Finally, it discusses current research efforts and future directions aimed at improving ViV procedural success and patient outcomes.

Thick endothelialization of the self-expandable valve causes delayed coronary obstruction.

Delayed coronary obstruction is a rare complication occurring after transcatheter aortic valve replacement (TAVR). Although TAVR has become popular, in some cases, the therapeutic strategy should be carefully selected depending on the patient's anatomical and/or functional restrictions. We report a rare case of delayed coronary obstruction in which coronary obstruction was caused by thick endothelialization of the nitinol frame of the prosthetic valve. A 79-year-old female who had undergone TAVR 4 months before presented with mild chest pain and was admitted to our institution. Computed tomography and coronary angiography revealed that the space from the sinus of Valsalva to the nitinol frame was narrow and separated from the inside of the nitinol frame because of critical endothelialization. Therefore, an emergency surgical aortic valve replacement was performed. The patient had an uneventful postoperative course and was discharged 20 days postoperatively without any complications.

Chimney Stenting vs BASILICA for Prevention of Acute Coronary Obstruction During Transcatheter Aortic Valve Replacement.

BACKGROUND: Coronary obstruction (CO) is a potentially life-threatening complication of transcatheter aortic valve replacement (TAVR). Chimney stenting or leaflet laceration with transcatheter electrosurgery (Bioprosthetic or Native Aortic Scallop Intentional Laceration to Prevent Iatrogenic Coronary Artery Obstruction [BASILICA]) are 2 techniques developed to prevent CO. OBJECTIVES: The aim of the present study was to compare periprocedural and 1-year outcomes of chimney and BASILICA in TAVR patients at high risk of CO. METHODS: This multicenter observational registry enrolled consecutive TAVR patients at high risk of CO, undergoing either preventive chimney stenting or BASILICA. Clinical success was defined as successful performance of the chimney or BASILICA technique without clinically relevant ostial CO. The primary endpoint was major adverse cardiovascular events, a composite of death, myocardial infarction, stroke, or unplanned target lesion coronary revascularization at 1 year. RESULTS: A total of 168 patients were included: 71 (42.3%) received chimney stenting, and 97 (57.7%) underwent BASILICA. Patients undergoing BASILICA had higher preprocedural risk of CO, as indicated by lower sinotubular junction height (18.2 ± 4.8 mm vs 14.8 ± 3.4 mm; P < 0.001) and diameter (28.2 ± 4.5 vs 26.8 ± 3.4; P = 0.029). Rates of periprocedural complications were similar between the 2 groups. Clinical success was 97.2% and 96.9% in chimney and BASILICA, respectively (P = 0.92). At 1-year follow-up, the cumulative incidence of major adverse cardiovascular events was 18.7% (95% CI: 11%-30.6%) in the chimney group and 19.9% (95% CI: 12.1%-31.5%) in the BASILICA group (log-rank P = 0.848), whereas chimney was associated with a numerically higher cardiovascular mortality than BASILICA (6.7% vs 1.3%; log-rank P = 0.168). CONCLUSIONS: Chimney stenting and BASILICA effectively prevent TAVR-induced acute CO. Both techniques seem to have comparable acceptable periprocedural and 1-year outcomes.

Clinical considerations and challenges in TAV-in-TAV procedures.

Transcatheter aortic valve replacement (TAVR) has emerged as a viable treatment for aortic valve disease, including low-risk patients. However, as TAVR usage increases, concerns about long-term durability and the potential for addition interventions have arisen. Transcatheter aortic valve (TAV)-in-TAV procedures have shown promise in selected patients in numerous registries, offering a less morbid alternative to TAVR explantation. In this review, the authors aimed to comprehensively review the experience surrounding TAV-in-TAV, summarize available data, discuss pre-procedural planning, highlight associated challenges, emphasize the importance of coronary obstruction assessment and provide insights into the future of this technique.

Risk of Sinus Sequestration During Redo Transcatheter Aortic Valve Implantation: The Prevalence, Predictors, and Risk Stratification.

The number of patients who underwent transcatheter aortic valve implantation (TAVI) with the potential for reintervention is steadily increasing; however, there is a risk of sinus sequestration (SS) during a redo TAVI. The prevalence, predictors, and risk stratification of the risk for SS remain uncertain. We analyzed computed tomography acquired from 263 patients who underwent TAVI between 2021 and 2022: balloon-expandable valve (BEV) (71%) and self-expandable valve (SEV) (29%). Patients were considered at risk for SS if they met the following: (1) BEV frame > sinotubular junction (STJ) or SEV neocommissure greater than the STJ and (2) valve-to-STJ <2 mm. The risk of left, right, and any SS in 51%, 50%, and 65%, respectively, did not differ between BEV and SEV. The predictors of any SS were the height of the left and right coronary cusp (odds ratio [OR] 0.81 and 0.71, cutoff 18.6 and 19.2 mm, respectively) and STJ minus the annulus diameter (OR 0.65, cutoff 3.7 mm) in BEV, and STJ diameter (OR 0.47, cutoff 27.6 mm) in SEV. The number of predictors stratified the risk of any SS: low risk with BEV at 0 predictors (14% at risk of SS), intermediate risk at 1 predictor (65%), high risk at 2 or 3 predictors (81% and 95%), and low risk with SEV at 0 predictors (33%) versus high risk at 1 predictor (91%). In conclusion, 2/3 of patients who underwent TAVI were at risk of SS. The height of the coronary cusp and the STJ diameter were associated with and adequately stratified the risk of SS.

Transcatheter Aortic Valve Replacement for Failed Surgical or Transcatheter Bioprosthetic Valves: A Comprehensive Review.

Transcatheter aortic valve replacement (TAVR) has proven to be a safe, effective, and less invasive approach to aortic valve replacement in patients with aortic stenosis. In patients who underwent prior aortic valve replacement, transcatheter and surgical bioprosthetic valve dysfunction may occur as a result of structural deterioration or nonstructural causes such as prosthesis-patient mismatch (PPM) and paravalvular regurgitation. Valve-in-Valve (ViV) TAVR is a procedure that is being increasingly utilized for the replacement of failed transcatheter or surgical bioprosthetic aortic valves. Data regarding long-term outcomes are limited due to the recency of the procedure's approval, but available data regarding the short- and long-term outcomes of ViV TAVR are promising. Studies have shown a reduction in perioperative and 30-day mortality with ViV TAVR procedures compared to redo surgical repair of failed bioprosthetic aortic valves, but 1-year and 5-year mortality rates are more controversial and lack sufficient data. Despite the reduction in 30-day mortality, PPM and rates of coronary obstruction are higher in ViV TAVR as compared to both redo surgical valve repair and native TAVR procedures. New transcatheter heart valve designs and new procedural techniques have been developed to reduce the risk of PPM and coronary obstruction. Newer generation valves, new procedural techniques, and increased operator experience with ViV TAVR may improve patient outcomes; however, further studies are needed to better understand the safety, efficacy, and durability of ViV TAVR.

Modeling of valve-in-valve transcatheter aortic valve implantation after aortic root replacement using a 3-dimensional artificial intelligence algorithm.

OBJECTIVE: Aortic root replacement requires construction of a composite valve-graft and reimplantation of coronary arteries. This study assessed the feasibility of valve-in-valve transcatheter aortic valve implantation after aortic root replacement. METHODS: A retrospective review was conducted on 74 consecutive patients who received a composite valve-graft at a single institution from 2019 to 2021. Forty patients had bioprosthetic valves with adequate postoperative gated computed tomographic angiography scans. Computational simulations of balloon and self-expanding transcatheter valve deployments were performed. The modeled coronary distances were compared with traditional, manually measured valve-to-coronary distances. RESULTS: There was a statistically significant difference in the modeled versus manual measurements of valve to coronary distances for all patients regardless of valve type or coronary artery analyzed (P < .05). Most patients are low risk for coronary obstruction per 3-dimensional modeling, including those with a valve-to-coronary distance <4 mm. Only 1 patient (2.5%) was at risk for coronary obstruction for the left coronary artery using a balloon valve. No other valve combination was considered high risk of coronary obstruction. Five patients (12.5%) were at risk for possible valve stent deformation at the outflow, due to angulation at the graft anastomosis. CONCLUSIONS: Following aortic root replacement, all patients were candidates for valve-in-valve procedure using 1 or both types of transcatheter heart valves. Self-expanding valves may be at higher risk for stent frame deformation at graft anastomotic lines and balloon-expandable valves may be at higher risk of coronary obstruction.