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. 2023 May 15;19(1):37-52.
doi: 10.4244/EIJ-D-22-00958.

Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery

Giuseppe Tarantini  1 , Gilbert Tang  2 , Luca Nai Fovino  1 , Daniel Blackman  3 , Nicolas M Van Mieghem  4 , Won-Keun Kim  5 , Nicole Karam  6 , Pedro Carrilho-Ferreira  7 , Stephane Fournier  8 , Jerzy Pręgowski  9 , Chiara Fraccaro  1 , Flavien Vincent  10 , Rui Campante Teles  11 , Darren Mylotte  12 , Ivan Wong  13 , Gintautas Bieliauskas  13 , Martin Czerny  14 , Nikolaos Bonaros  15 , Alessandro Parolari  16 , Darius Dudek  17   18 , Didier Tchetche  19 , Hélène Eltchaninoff  20 , Ole de Backer  13 , Giulio Stefanini  21 , Lars Sondergaard  13
Affiliations

Management of coronary artery disease in patients undergoing transcatheter aortic valve implantation. A clinical consensus statement from the European Association of Percutaneous Cardiovascular Interventions in collaboration with the ESC Working Group on Cardiovascular Surgery

Giuseppe Tarantini et al. EuroIntervention. .

Abstract

Significant coronary artery disease (CAD) is a frequent finding in patients with severe aortic stenosis undergoing transcatheter aortic valve implantation (TAVI), and the management of these two conditions becomes of particular importance with the extension of the procedure to younger and lower-risk patients. Yet, the preprocedural diagnostic evaluation and the indications for treatment of significant CAD in TAVI candidates remain a matter of debate. In this clinical consensus statement, a group of experts from the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery aims to review the available evidence on the topic and proposes a rationale for the diagnostic evaluation and indications for percutaneous revascularisation of CAD in patients with severe aortic stenosis undergoing transcatheter treatment. Moreover, it also focuses on commissural alignment of transcatheter heart valves and coronary re-access after TAVI and redo-TAVI.

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Conflict of interest statement

G. Tarantini reports lecture fees from Medtronic, Edwards Lifesciences, Abbott Vascular, and Boston Scientific. H. Eltchaninoff reports lecture fees from Edwards Lifesciences. D. Blackman reports consulting and lecture fees from Medtronic, Edwards Lifesciences, Abbott Vascular, and Boston Scientific. N. Bonaros reports lecture fees from Edwards Lifesciences and Medtronic. N. Karam reports consulting and lecture fees from Medtronic, Edwards Lifesciences, and Abbott Vascular. D. Mylotte reports consulting fees from Medtronic, Boston Scientific, and MicroPort. P. Carrilho-Ferreira reports lecture fees from Biotronik and Medtronic. N. Van Mieghem reports consulting fees from Biotronik, Boston Scientific, Abbott Vascular, Medtronic, PulseCath BV, and Abiomed; and research grants from Abbott Vascular, Edwards Lifesciences, Boston Scientific, Abiomed, Medtronic, PulseCath BV, Amgen, and Daiichi Sankyo. W-K. Kim reports lecture fees from Abbott, Boston Scientific, Edwards Lifesciences, Medtronic, and Meril Life Sciences. G. Tang is a physician proctor, physician advisory board member and consultant for Medtronic; physician advisory board member and consultant for Abbott Structural Heart; physician advisory board member for JenaValve; consultant for NeoChord; and has received speaker honoraria from Siemens Healthineers. O. De Backer received institutional research grants and consulting fees from Abbott, Boston Scientific, and Medtronic. L. Sondergaard received consultant fees and/or institutional research grants from Abbott, Boston Scientific, Medtronic, and SMT. The other authors have no conflicts of interest to declare.The Guest Editor reports lecture fees paid to his institution from Amgen, Bayer Healthcare, Biotronik, Boehringer Ingelheim, Boston Scientific, Daiichi Sankyo, Edwards Lifesciences, Ferrer, Pfizer, and Novartis; and consultancy fees paid to his institution from Boehringer.

Figures

Figure 1
Figure 1. Prevalence of coronary artery disease (CAD) in patients treated with transcatheter aortic valve implantation as reported in randomised clinical trials (blue columns) and real-world registries (red columns).
STS/ACC TVT: Society of Thoracic Surgeons/American College of Cardiology Transcatheter Valve Therapy
Figure 2
Figure 2. Systolic coronary flow before and after TAVI.
TAVI: transcatheter aortic valve implantation. Reproduced with permission.
Figure 3
Figure 3. THV leaflet height with respect to recommended annular positioning.
THV: transcatheter heart valve
Figure 4
Figure 4. Coronary access according to valve design and implantation depth.
Coronary engagement after previous SAPIEN 3 (A) implantation is commonly feasible with standard catheters, and the access route may be least impaired (green arrow); engagement across the stent frame (red arrow) may become necessary only in the case of high THV positioning or low coronary take-off. Potential access routes for the ACURATE neo valve (B) may be via the stabilisation arches (red arrow) or from outside the valve frame (dotted green arrow). The common access route in tall-frame valves ([C] Portico/Navitor; [D] Evolut) is across the uncovered stent struts above the leaflet plane (red arrows), whereas, especially in patients with a wide sinotubular junction or sinus of Valsalva, an access route from outside the valve frame (dotted green arrows) may be an alternative. The lower leaflet position and the larger cells of the Portico/Navitor THV stent frame may facilitate coronary catheterisation in comparison with the Evolut platform. Regardless of the THV type, correct commissural alignment of the prosthesis will usually facilitate coronary access. THV: transcatheter heart valve
Figure 5
Figure 5. The S-curve of different fluoroscopic working views for transcatheter aortic valve deployment.
The S-curve identifies infinite patient-specific fluoroscopic projections in which the 3 aortic cusps are aligned on the same plane. Among them, there are 3 projections where the 3 cusps are equidistant (NRL, LNR and RLN) and 3 other projections where 2 of 3 cusps are overlapping (RL cusp overlap, LN cusp overlap, NR cusp overlap). The most widely used implanting views are the 3-cusp coplanar view NRL and the RL cusp overlap view. CAU: caudal; CRA: cranial; L: left coronary cusp; LAO: left anterior oblique; LCA: left coronary artery; N: non-coronary cusp; R: right coronary cusp; RAO: right anterior oblique; RCA: right coronary artery
Figure 6
Figure 6. THV-specific fluoroscopic markers of the THV commissural posts.
THV-specific fluoroscopic markers identifying prosthetic neocommissures in different types of expanded and crimped THVs. A) CoreValve Evolut platform; B) ACURATE neo2 platform; C) Portico/Navitor platform. THV: transcatheter heart valve. Adapted with permission from.
Figure 7
Figure 7. Implantation steps to obtain commissural alignment with different type of THVs.
The figure shows the suggested rotation of the delivery system at the time of insertion (A, B, C), the expected fluoroscopic view of radiopaque markers in the RL cusp overlap view when the THV is still crimped (D, E, F) and the final fluoroscopic view after valve deployment in the same RL cusp overlap view (G, H, I) when implanting different THVs pursuing commissural alignment. If, before valve deployment, the fluoroscopic view is different from expected in the cusp overlap view, the operator should slowly torque the delivery catheter clockwise in order to obtain the desired orientation. Even if a gentle torque could be attempted with the THV at the level of the aortic valve, with the CoreValve platform, it is advisable to perform this manoeuvre only in the descending aorta to facilitate torquing force transmission through the delivery system. CF: central front; LAO: left anterior oblique; OC: outer curve; THV: transcatheter heart valve. Adapted with permission from.
Figure 8
Figure 8. Coronary access after TAVI-in-TAVI with different combinations of SAPIEN and CoreValve/Evolut transcatheter heart valves, depending on aortic root anatomy.
STJ: sinotubular junction; TAVI: transcatheter aortic valve implantation. Adapted with permission from.
See this image and copyright information in PMC

References

    1. Vahanian A, Beyersdorf F, Praz F, Milojevic M, Baldus S, Bauersachs J, Capodanno D, Conradi L, De Bonis, De Paulis, Delgado V, Freemantle N, Haugaa KH, Jeppsson A, Jüni P, Pierard L, Prendergast BD, Sádaba JR, Tribouilloy C, Wojakowski W. 2021 ESC/EACTS Guidelines for the management of valvular heart disease. EuroIntervention. 2022;17:e1126–96. - PMC - PubMed
    1. Tarantini G, Nai Fovino, Gersh BJ. Transcatheter aortic valve implantation in lower-risk patients: what is the perspective? Eur Heart J. 2018;39:658–66. - PubMed
    1. Tarantini G, Lefèvre T, Terkelsen CJ, Frerker C, Ohlmann P, Mojoli M, Eltchaninoff H, Pinaud F, Redwood S, Windecker S. One-Year Outcomes of a European Transcatheter Aortic Valve Implantation Cohort According to Surgical Risk. Circ Cardiovasc Interv. 2019;12:e006724. - PubMed
    1. Leon MB, Smith CR, Mack M, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Brown DL, Block PC, Guyton RA, Pichard AD, Bavaria JE, Herrmann HC, Douglas PS, Petersen JL, Akin JJ, Anderson WN, Wang D, Pocock S PARTNER Trial Investigators. Transcatheter aortic-valve implantation for aortic stenosis in patients who cannot undergo surgery. N Engl J Med. 2010;363:1597–607. - PubMed
    1. Smith CR, Leon MB, Mack MJ, Miller DC, Moses JW, Svensson LG, Tuzcu EM, Webb JG, Fontana GP, Makkar RR, Williams M, Dewey T, Kapadia S, Babaliaros V, Thourani VH, Corso P, Pichard AD, Bavaria JE, Herrmann HC, Akin JJ, Anderson WN, Wang D, Pocock SJ PARTNER Trial Investigators. Transcatheter versus surgical aortic-valve replacement in high-risk patients. N Engl J Med. 2011;364:2187–98. - PubMed

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