The prevalence of coronary artery disease (CAD) in the setting of transcatheter aortic valve replacement (TAVR) patients is very high, said Giuseppe Tarantini, MD, PhD, Professor and Chief of Interventional Cardiology Unit, University of Padua, Italy, in his presentation “Management of CAD Before and After TAVR” on June 7^th at the TVT conference in Phoenix, Arizona. The treatment of CAD in the setting of TAVR was the subject of a recently published consensus statement by the European Association of Percutaneous Cardiovascular Interventions (EAPCI) in collaboration with the European Society of Cardiology (ESC) Working Group on Cardiovascular Surgery.¹ Dr. Tarantini discussed three main areas from the consensus statement for clinical practice: preprocedural planning, valve choice, and transcatheter heart valve (THV) in THV procedures.

Preprocedural Planning

While PCI can be performed before or after TAVR, there are advantages to PCI prior to TAVR, most crucial of which is freedom of coronary access. The general recommendation is to treat with PCI prior to TAVR. The literature contains some evidence in support of this approach, including from the FRANCE 2 registry, where positive outcomes were seen from treating a stenosis greater than 70% in the proximal left anterior descending (LAD) coronary artery prior to TAVR. Similarly, Dr. Tarantini said treating patients with acute coronary syndromes, severe angina, or those patients with a greater than 90% proximal lesion prior to TAVR is reasonable and can help avoid delaying the TAVR procedure in these patients, potentially increasing hemodynamic stability and procedural safety for TAVR. Disadvantages of PCI prior to TAVR include being committed to dual antiplatelets, repeated vascular access, and less-reliable fractional flow reserve/instantaneous wave-free ratio measurements. He also noted that concomitant PCI and TAVR can result in increased contrast use. For a very complex PCI, performing the procedure after TAVR may increase hemodynamic stability, said Dr. Tarantini, “especially when you have severe left ventricular dysfunction. You can stage or do [PCI] in the same setting, depending on the contrast risk to the patient.” It is particularly important that when PCI after TAVR is performed, the transcatheter heart valve choice and implantation technique are aimed at preserving coronary artery access.

Valve Choice

The Sapien 3 (Edwards Lifesciences) has a short frame that typically permits the upper part of the strut to be placed below the coronary artery ostium and thus below the risk plane, so the width of the valve cell area is not as much as of a concern, said Dr. Tarantini, although in 15% of cases, placement of the Sapien 3 may be necessary above the coronary artery. The self-expandable valves (Acurate Neo [Boston Scientific] Portico [Abbott Vascular], and Evolut R [Medtronic]) vary widely in cell width, with the Acurate Neo having the largest width and Evolut R the smallest. Additional differentiation points between valves include the curtain and the risk plane. Commissural triangle sizing is important when the valve is misaligned to the coronary artery. Dr. Tarantini noted that the commissure triangle for the Evolut is significantly larger than the Acurate Neo. He also discussed the concept of commissural alignment. “What is not a wish but is a must, in 2023,” said Dr. Tarantini, in 79- or 80-year-old patients, is to go with a valve orientation that allows for clear coronary access. The major predictors for impaired coronary access are the misalignment of the valve, the sinus of Valsava sizing relationship to the valve, and the width of the ascending aorta. Transcatheter heart valves all have radiopaque markers and different recommendations for orientation, and Dr. Taranatini also recommended positioning of the flash port within 1 and 3 o’clock for self-expandable valves.

Coronary Access in THV-in-THV Procedures

For THV in THV, a short frame valve such as the Sapien 3 should guarantee an easy coronary access. For supra-annular valves, Dr. Tarantini shared 3 imaging studies showing that selective cannulation can be impaired in up to two-thirds of cases. Not all self-expanding THVs are equal in terms of coronary access, particularly for two risk planes. The first risk plane involves the inner skirt of the valve, affecting the first TAVR, where the valve skirt does not permit cannulation of the coronary artery. The second risk plane is in THV in THV, creating, in essence, a covered stent in front of the coronary ostium. The height of the risk plane varies across the different valves and is also in relation to valve implantation depth. Challenges in THV-in-TVH procedures can occur as a result of leaflet height, asymmetric commissures level, and valve cell design. Dr. Tarantini described 3 types of transcatheter heart valve degeneration (Types 1, 2a, and 2b) to orient THV-in-THV procedure planning. Of the 3 types, only Type 2b is not feasible for THV-in-THV, since the coronary ostia is located below the risk plane (thus access is below the risk plane) and valve-to-aorta distance (VTA) is <2 mm. Dr. Tarantini also mentioned the BASILICA and Chimney procedures, noting  the problem is their reproducibility. He concluded with the video of a bench test of an Acurate Neo, discussing how measuring VTA differently than for a surgical valve shows coronary cannulation may be possible not only from outside the valve, but also between the leaflet movements and the frame of the valve, with a possible 1 to 3 mm available, depending on the width of the ascending aorta.

Reference

1. Tarantini G, Tang G, Nai Fovino L, Blackman D, Van Mieghem NM, Kim WK, Karam N, Carrilho-Ferreira P, Fournier S, Pręgowski J, Fraccaro C, Vincent F, Campante Teles R, Mylotte D, Wong I, Bieliauskas G, Czerny M, Bonaros N, Parolari A, Dudek D, Tchetche D, Eltchaninoff H, de Backer O, Stefanini G, Sondergaard L. 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. EuroIntervention. 2023 May 15;19(1):37-52. doi: 10.4244/EIJ-D-22-00958

Find more: 
TVT Newsroom (With a Special Focus on TAVR)

Dr. Tarantini presented "Management of CAD Before and After TAVR" on June 7th at TVT. Find his slides here.